Provider Demographics
NPI:1629490701
Name:BATES, KRISTINA KANIA (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:KANIA
Last Name:BATES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:M
Other - Last Name:KANIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE A200
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3580
Practice Address - Country:US
Practice Address - Phone:864-454-5115
Practice Address - Fax:864-454-5111
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1407103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0611Medicaid