Provider Demographics
NPI:1235468836
Name:LASTRA, KRISTEN NIAN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NIAN
Last Name:LASTRA
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 1:1300 MONTECITO AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-4549
Mailing Address - Country:US
Mailing Address - Phone:650-386-6118
Mailing Address - Fax:
Practice Address - Street 1:1300 MONTECITO AVE APT 5
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-4549
Practice Address - Country:US
Practice Address - Phone:650-386-6118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children