Healthcare Provider Details

I. General information

NPI: 1053145359
Provider Name (Legal Business Name): KRISTINE ATIENZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 09/24/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W 5TH ST STE 308
SAN PEDRO CA
90731-2750
US

IV. Provider business mailing address

305 WEST 5TH STREET SUITE 308
SAN PEDRO CA
90731
US

V. Phone/Fax

Practice location:
  • Phone: 562-388-8118
  • Fax:
Mailing address:
  • Phone: 424-570-6955
  • Fax: 424-363-1721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number165013
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: