Provider Demographics
NPI:1770986390
Name:DIGIACOMO, KINDRA
Entity type:Individual
Prefix:
First Name:KINDRA
Middle Name:
Last Name:DIGIACOMO
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 1:4659 SHADE TREE WAY
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-5836
Mailing Address - Country:US
Mailing Address - Phone:916-532-6733
Mailing Address - Fax:
Practice Address - Street 1:775 SUNRISE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4523
Practice Address - Country:US
Practice Address - Phone:916-532-6733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-28
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79820106H00000X
CA93361106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist