Provider Demographics
NPI:1457584542
Name:MIHOLICH, KRISTINA MARIE LEE (PSYD)
Entity type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:MARIE LEE
Last Name:MIHOLICH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KRISTINA
Other - Middle Name:MARIE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:12843 ISOCOMA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-3612
Mailing Address - Country:US
Mailing Address - Phone:619-301-3606
Mailing Address - Fax:
Practice Address - Street 1:158 C AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1420
Practice Address - Country:US
Practice Address - Phone:619-435-5400
Practice Address - Fax:619-435-5401
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA25801103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program