Provider Demographics
NPI:1609439751
Name:PAN, KRISTIE M (BCBA)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:M
Last Name:PAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 HOLYOKE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94134-1737
Mailing Address - Country:US
Mailing Address - Phone:415-816-2705
Mailing Address - Fax:
Practice Address - Street 1:1720 S AMPHLETT BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2710
Practice Address - Country:US
Practice Address - Phone:650-483-9174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-33500103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst