MEDICARE: KRISTIN RENEE GORADIETSKY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY36152	CA

General Provider Information

NPI Number	:	1427381086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN RENEE GORADIETSKY

Provider Business Mailing Address
First Line	:	2512 FOOTHILL BLVD
Second Line	:
City	:	LA CRESCENTA
State	:	CA
Zip	:	91214-3506
Country	:	US
Telephone Number	:	626-214-5092
Fax Number	:

Provider Business Practice Location Address
First Line	:	2512 FOOTHILL BLVD
Second Line	:
City	:	LA CRESCENTA
State	:	CA
Zip	:	91214-3506
Country	:	US
Telephone Number	:	626-214-5092
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2009
Last Update Date	:	09/30/2025

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