Provider Demographics
NPI:1245510353
Name:ANDERSON, KRISTOFER R (MFT)
Entity type:Individual
Prefix:
First Name:KRISTOFER
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 E GUASTI RD
Mailing Address - Street 2:SUITE 100-42
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-8660
Mailing Address - Country:US
Mailing Address - Phone:909-262-1768
Mailing Address - Fax:
Practice Address - Street 1:3200 E GUASTI RD
Practice Address - Street 2:SUITE 100-42
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-8660
Practice Address - Country:US
Practice Address - Phone:909-262-1768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45388106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist