Provider Demographics
NPI:1982668711
Name:REYNOSO, KRISTINA (PHD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:
Last Name:REYNOSO
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 1:2740 FULTON AVE
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-5108
Mailing Address - Country:US
Mailing Address - Phone:415-244-3616
Mailing Address - Fax:
Practice Address - Street 1:2740 FULTON AVE
Practice Address - Street 2:SUITE 100B
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-5108
Practice Address - Country:US
Practice Address - Phone:415-244-3616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19132103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL191321Medicare ID - Type Unspecified