Provider Demographics
NPI:1497876890
Name:POULSEN-SORIA, KRISTA NICOLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:NICOLE
Last Name:POULSEN-SORIA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:54 PENNY LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-6012
Mailing Address - Country:US
Mailing Address - Phone:831-728-2040
Mailing Address - Fax:831-728-2040
Practice Address - Street 1:54 PENNY LN
Practice Address - Street 2:SUITE B
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-6012
Practice Address - Country:US
Practice Address - Phone:831-728-2040
Practice Address - Fax:831-728-2040
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20116103TC0700X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered174400000XOther Service ProvidersSpecialist