Healthcare Provider Details

I. General information

NPI: 1104112663
Provider Name (Legal Business Name): KRISTINA MOHRHARDT CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 03/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3853 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

IV. Provider business mailing address

PO BOX 83188
SAN DIEGO CA
92138-3188
US

V. Phone/Fax

Practice location:
  • Phone: 619-933-4051
  • Fax:
Mailing address:
  • Phone: 619-933-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number41024
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: