Provider Demographics
NPI:1922675834
Name:KOMADA, KRISTINE ANNE (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ANNE
Last Name:KOMADA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4809 216TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1334
Mailing Address - Country:US
Mailing Address - Phone:347-453-6171
Mailing Address - Fax:
Practice Address - Street 1:BETHANY HOUSE II
Practice Address - Street 2:199-19 113TH AVENUE
Practice Address - City:ST ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412
Practice Address - Country:US
Practice Address - Phone:917-685-7145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9182103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist