Provider Demographics
NPI:1225606510
Name:PADDOCK, KRISTI LEANN
Entity Type:Individual
Prefix:MS
First Name:KRISTI
Middle Name:LEANN
Last Name:PADDOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22575 LEANNE TER APT 403
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-6856
Mailing Address - Country:US
Mailing Address - Phone:571-528-4014
Mailing Address - Fax:
Practice Address - Street 1:22375 BRODERICK DR
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-9371
Practice Address - Country:US
Practice Address - Phone:571-375-0214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-21-171923106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician