Healthcare Provider Details

I. General information

NPI: 1093152498
Provider Name (Legal Business Name): KEANNA BRISTO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2013
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9510 ELK GROVE FLORIN RD RM 110
ELK GROVE CA
95624-1801
US

IV. Provider business mailing address

9510 ELK GROVE FLORIN RD RM 110
ELK GROVE CA
95624-1801
US

V. Phone/Fax

Practice location:
  • Phone: 916-686-7568
  • Fax: 916-689-7596
Mailing address:
  • Phone: 916-686-7568
  • Fax: 916-689-7596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number109939
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: