Provider Demographics
NPI:1336602044
Name:DEWINDT, KRISTA
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:
Last Name:DEWINDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:TERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2085 RUSTIN AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2498
Mailing Address - Country:US
Mailing Address - Phone:951-955-8000
Mailing Address - Fax:951-955-8010
Practice Address - Street 1:2085 RUSTIN AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2498
Practice Address - Country:US
Practice Address - Phone:951-955-8000
Practice Address - Fax:951-955-8010
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF1085052225500000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF1085052OtherCSUB