Healthcare Provider Details

I. General information

NPI: 1811391758
Provider Name (Legal Business Name): KRISTA MARIE KEY SUDRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 COLOMA ST
PLACERVILLE CA
95667-4406
US

IV. Provider business mailing address

2844 COLOMA ST
PLACERVILLE CA
95667-4406
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-9240
  • Fax: 530-626-8992
Mailing address:
  • Phone: 530-626-9240
  • Fax: 530-626-8992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRC10270
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: