Provider Demographics
NPI:1669635272
Name:MADRID, KRYSTLE KATIE (PSYD)
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:KATIE
Last Name:MADRID
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4821 LANKERSHIM BLVD STE F-373
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-4538
Mailing Address - Country:US
Mailing Address - Phone:213-290-0445
Mailing Address - Fax:
Practice Address - Street 1:4821 LANKERSHIM BLVD STE F-373
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-4538
Practice Address - Country:US
Practice Address - Phone:213-290-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27609103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical