Healthcare Provider Details

I. General information

NPI: 1619005006
Provider Name (Legal Business Name): KRISTY KUDO I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11721 TELEGRAPH RD
SANTA FE SPRINGS CA
90670-3674
US

IV. Provider business mailing address

11721 TELEGRAPH RD STE A
SANTA FE SPRINGS CA
90670-6835
US

V. Phone/Fax

Practice location:
  • Phone: 562-949-8455
  • Fax:
Mailing address:
  • Phone: 562-949-8455
  • Fax: 562-949-4807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 26022
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: