Provider Demographics
NPI:1417668344
Name:KERATISOMPHON, KISTIYAPORN (ACSW)
Entity Type:Individual
Prefix:
First Name:KISTIYAPORN
Middle Name:
Last Name:KERATISOMPHON
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9417 NAGLE AVE
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-5914
Mailing Address - Country:US
Mailing Address - Phone:818-818-1600
Mailing Address - Fax:
Practice Address - Street 1:405 W 5TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4599
Practice Address - Country:US
Practice Address - Phone:714-834-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-12
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW1112341041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical