Provider Demographics
NPI:1437585296
Name:IRESON, KRISTINA ELISE (LCSW 80918)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ELISE
Last Name:IRESON
Suffix:
Gender:F
Credentials:LCSW 80918
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:E
Other - Last Name:DAMOTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 661
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-0661
Mailing Address - Country:US
Mailing Address - Phone:650-832-6900
Mailing Address - Fax:
Practice Address - Street 1:957 INDUSTRIAL RD STE B
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-4152
Practice Address - Country:US
Practice Address - Phone:650-832-6900
Practice Address - Fax:650-620-9549
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPPS1041S0200X
CA809181041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health