Healthcare Provider Details

I. General information

NPI: 1528191699
Provider Name (Legal Business Name): KRISTA FREECE PH.D., PLLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E MAIN ST
EL CAJON CA
92021-5204
US

IV. Provider business mailing address

42180 FORD RD SUITE 305
CANTON MI
48187-3673
US

V. Phone/Fax

Practice location:
  • Phone: 619-593-5100
  • Fax:
Mailing address:
  • Phone: 734-981-3100
  • Fax: 734-981-6366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301014786
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY27847
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: