Provider Demographics
NPI:1932975125
Name:CAMPBELL, KRISTA KAY
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:KAY
Last Name:CAMPBELL
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 1:5001 WINDPLAY DR STE 1
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-9833
Mailing Address - Country:US
Mailing Address - Phone:916-316-5819
Mailing Address - Fax:
Practice Address - Street 1:5001 WINDPLAY DR STE 1
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9833
Practice Address - Country:US
Practice Address - Phone:916-316-5819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103290390200000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health