Provider Demographics
NPI:1801095419
Name:ANDRES, KRISTINE JOANNE (COTA/L)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:JOANNE
Last Name:ANDRES
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 SAGEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3527
Mailing Address - Country:US
Mailing Address - Phone:209-688-4104
Mailing Address - Fax:
Practice Address - Street 1:1304 SAGEWOOD CT
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3527
Practice Address - Country:US
Practice Address - Phone:209-688-4104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA855174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist