Provider Demographics
NPI:1912202235
Name:KWAK-REID, KRISTELLE MYUNG (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTELLE
Middle Name:MYUNG
Last Name:KWAK-REID
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KRIS, MYUNG
Other - Middle Name:HEE
Other - Last Name:KWAK-REID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12810 WOODLEY AVENUE
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344
Mailing Address - Country:US
Mailing Address - Phone:562-301-5262
Mailing Address - Fax:
Practice Address - Street 1:6551 VAN NUYS BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-1442
Practice Address - Country:US
Practice Address - Phone:818-988-6335
Practice Address - Fax:818-988-6817
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA270021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical