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
State | License ID | Taxonomies |
---|---|---|
CA | PPS | 1041S0200X |
CA | 80918 | 1041C0700X, 101YM0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No | 1041S0200X | Behavioral Health & Social Service Providers | Social Worker | School |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |