Healthcare Provider Details

I. General information

NPI: 1356831374
Provider Name (Legal Business Name): KRISTIN ANN GAINES MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN ANN BONFIGLIO MSW

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 E FRUIT ST
SANTA ANA CA
92701-4206
US

IV. Provider business mailing address

1207 E FRUIT ST
SANTA ANA CA
92701-4206
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-9373
  • Fax: 714-953-7375
Mailing address:
  • Phone: 714-953-9373
  • Fax: 714-953-7375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number36247
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: