Provider Demographics
NPI:1760592901
Name:BANAZEK, KRYSTA A (MFT)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTA
Middle Name:A
Last Name:BANAZEK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E 3RD AVE
Mailing Address - Street 2:SUITE 207A
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-4051
Mailing Address - Country:US
Mailing Address - Phone:650-576-6764
Mailing Address - Fax:
Practice Address - Street 1:205 E 3RD AVE
Practice Address - Street 2:SUITE 207A
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4051
Practice Address - Country:US
Practice Address - Phone:650-576-6764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43328106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist