Healthcare Provider Details

I. General information

NPI: 1538531900
Provider Name (Legal Business Name): KR PSYCHOLOGICAL SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 04/14/2024
Certification Date: 04/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30011 IVY GLENN DR STE 120
LAGUNA NIGUEL CA
92677-5041
US

IV. Provider business mailing address

90 VANTIS DR UNIT 6021
ALISO VIEJO CA
92656-2547
US

V. Phone/Fax

Practice location:
  • Phone: 714-812-1916
  • Fax: 949-305-8286
Mailing address:
  • Phone: 714-812-1916
  • Fax: 949-305-8286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY20067
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISTINA BROSIUS-RODRIGUEZ
Title or Position: CEO
Credential: PSY.D.
Phone: 714-812-1916