Provider Demographics
NPI:1407307762
Name:ABDULLAHI, KRISSIE RAQUEL
Entity Type:Individual
Prefix:
First Name:KRISSIE
Middle Name:RAQUEL
Last Name:ABDULLAHI
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 1:1414 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1515
Mailing Address - Country:US
Mailing Address - Phone:209-468-6208
Mailing Address - Fax:209-468-8700
Practice Address - Street 1:500 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9693
Practice Address - Country:US
Practice Address - Phone:209-468-6208
Practice Address - Fax:209-468-7032
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health