Provider Demographics
NPI:1649782707
Name:IZEDI, KRISTINE VERONICA (MS)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:VERONICA
Last Name:IZEDI
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:V
Other - Last Name:MAC DONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4740 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-2005
Mailing Address - Country:US
Mailing Address - Phone:626-859-2089
Mailing Address - Fax:626-859-6537
Practice Address - Street 1:4740 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-2005
Practice Address - Country:US
Practice Address - Phone:626-859-2089
Practice Address - Fax:626-859-6537
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF101512106H00000X
CAAMFT101512106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist