Healthcare Provider Details

I. General information

NPI: 1184552523
Provider Name (Legal Business Name): KRISTIAN KING
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 S BASCOM AVE STE 216
SAN JOSE CA
95124-2675
US

IV. Provider business mailing address

1111 BOWERS AVE
SOUTH LAKE TAHOE CA
96150-8480
US

V. Phone/Fax

Practice location:
  • Phone: 208-721-2933
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number160499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: