Healthcare Provider Details

I. General information

NPI: 1851203848
Provider Name (Legal Business Name): KRISTOPHER RILEY STATHAM PPSC, CWC II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11601 MAIN ST
SUNOL CA
94586-9519
US

IV. Provider business mailing address

407 SANCHEZ ST APT 2150
SAN FRANCISCO CA
94114-2080
US

V. Phone/Fax

Practice location:
  • Phone: 669-241-0420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberBA0F6A6A74
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number260077394
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: