Healthcare Provider Details

I. General information

NPI: 1972168961
Provider Name (Legal Business Name): KRISTINA SUMMERS SUDRC 9427
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 W OCEAN AVE
LOMPOC CA
93436-6630
US

IV. Provider business mailing address

1933 ELMWOOD DR
SANTA MARIA CA
93455-2820
US

V. Phone/Fax

Practice location:
  • Phone: 805-736-0357
  • Fax: 800-969-9350
Mailing address:
  • Phone: 805-714-7382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRC9427
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9427
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerCADTP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: