Provider Demographics
NPI:1467906768
Name:JUSTICE GORDON, KRISTINA ELIZABETH (LMFT, PPSC)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ELIZABETH
Last Name:JUSTICE GORDON
Suffix:
Gender:F
Credentials:LMFT, PPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W FOOTHILL BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-2783
Mailing Address - Country:US
Mailing Address - Phone:909-450-5090
Mailing Address - Fax:
Practice Address - Street 1:415 W FOOTHILL BLVD STE 105
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-2783
Practice Address - Country:US
Practice Address - Phone:909-450-5090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAAMFT105367101YM0800X
CALMFT119699106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health