Provider Demographics
NPI:1932550407
Name:SKIPPERGOSH, KRISTYNE (ASW)
Entity Type:Individual
Prefix:
First Name:KRISTYNE
Middle Name:
Last Name:SKIPPERGOSH
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 GATEWAY CENTER WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4550
Mailing Address - Country:US
Mailing Address - Phone:619-398-2156
Mailing Address - Fax:
Practice Address - Street 1:5252 BALBOA AVE STE 800
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6970
Practice Address - Country:US
Practice Address - Phone:619-404-0578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77865101YM0800X
MI6801099324104100000X
CA907841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker