Healthcare Provider Details

I. General information

NPI: 1720322951
Provider Name (Legal Business Name): KRISTINA MARIE HARRIS CADC-II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2012
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 COLOMA ST
PLACERVILLE CA
95667-4406
US

IV. Provider business mailing address

3201A SAND RIDGE CT
EL DORADO CA
95623-4949
US

V. Phone/Fax

Practice location:
  • Phone: 530-642-1715
  • Fax: 530-642-2064
Mailing address:
  • Phone: 530-344-2797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAII057550518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: