Healthcare Provider Details

I. General information

NPI: 1063542835
Provider Name (Legal Business Name): KRISTINE I VINDUA PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 E. HIGHLAND AVENUE PATTON STATE HOSPITAL
PATTON CA
92369
US

IV. Provider business mailing address

1600 9TH STREET ROOM 205, MAILSTOP 2-3
SACRAMENTO CA
94244-2020
US

V. Phone/Fax

Practice location:
  • Phone: 909-425-7679
  • Fax: 909-425-6635
Mailing address:
  • Phone: 916-654-3482
  • Fax: 916-653-4587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY24489
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: