Provider Demographics
NPI:1750148839
Name:MAKENA, KRISTIN M (LICENSED EDUC PSYCH)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:M
Last Name:MAKENA
Suffix:
Gender:F
Credentials:LICENSED EDUC PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1375 E GRAND AVE # 103-327
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-2421
Mailing Address - Country:US
Mailing Address - Phone:619-977-7224
Mailing Address - Fax:
Practice Address - Street 1:1461 HIGUERA ST STE D
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2948
Practice Address - Country:US
Practice Address - Phone:619-977-7224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA3575103TC1900X, 103TM1800X, 103TS0200X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool