Provider Demographics
NPI:1801365309
Name:ADAMS, KRYSTINE NICHOLE
Entity Type:Individual
Prefix:
First Name:KRYSTINE
Middle Name:NICHOLE
Last Name:ADAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 D ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-5952
Mailing Address - Country:US
Mailing Address - Phone:530-742-7747
Mailing Address - Fax:
Practice Address - Street 1:1496 N BEALE RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-6205
Practice Address - Country:US
Practice Address - Phone:530-749-8640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1324201018101YA0400X
171M00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator