Provider Demographics
NPI:1750637658
Name:KINGSLAND, CONNIE MARIE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:MARIE
Last Name:KINGSLAND
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 W ALMOND AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3401
Mailing Address - Country:US
Mailing Address - Phone:714-904-3352
Mailing Address - Fax:714-992-5259
Practice Address - Street 1:1619 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-4015
Practice Address - Country:US
Practice Address - Phone:714-904-3352
Practice Address - Fax:714-992-5259
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-28
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 51902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist