Provider Demographics
NPI:1528191699
Name:FREECE, KRISTA (PHD, PLLC)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:FREECE
Suffix:
Gender:F
Credentials:PHD, PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42180 FORD RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3673
Mailing Address - Country:US
Mailing Address - Phone:734-981-3100
Mailing Address - Fax:734-981-6366
Practice Address - Street 1:1630 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5204
Practice Address - Country:US
Practice Address - Phone:619-593-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014786103TC0700X
CAPSY27847103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY27847OtherBOARD OF PSYCHOLOGY
MI6301014786OtherBOARD OF PSYCHOLOGY