Provider Demographics
NPI:1962590018
Name:BRADY, KRISTINE LYNN (PHD)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:LYNN
Last Name:BRADY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 HUMMOCK LN
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1908
Mailing Address - Country:US
Mailing Address - Phone:760-436-9268
Mailing Address - Fax:
Practice Address - Street 1:345 SAXONY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2787
Practice Address - Country:US
Practice Address - Phone:760-420-4045
Practice Address - Fax:760-632-8875
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19375103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral