Provider Demographics
NPI:1700475357
Name:GEBREKRISTOS, SELAM HABTE
Entity Type:Individual
Prefix:
First Name:SELAM
Middle Name:HABTE
Last Name:GEBREKRISTOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5365 REDDING RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-1120
Mailing Address - Country:US
Mailing Address - Phone:619-788-4628
Mailing Address - Fax:
Practice Address - Street 1:5365 REDDING RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-1120
Practice Address - Country:US
Practice Address - Phone:619-788-4628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123796106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist