Provider Demographics
NPI:1588026611
Name:CARDENAS-GACHUPIN, KRISTAL (CATC)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:
Last Name:CARDENAS-GACHUPIN
Suffix:
Gender:F
Credentials:CATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 CALLE MONTECITO
Mailing Address - Street 2:64
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-5269
Mailing Address - Country:US
Mailing Address - Phone:719-220-0721
Mailing Address - Fax:
Practice Address - Street 1:3940 HOME AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-5952
Practice Address - Country:US
Practice Address - Phone:619-262-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC0502041556101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$OtherSSN