Healthcare Provider Details

I. General information

NPI: 1093838500
Provider Name (Legal Business Name): KRISTAL ALEXIS AUDOMA LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 02/14/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 ANGELES VISTA BLVD
VIEW PARK CA
90043-1648
US

IV. Provider business mailing address

10046 FREMONT AVE
MONTCLAIR CA
91763-3224
US

V. Phone/Fax

Practice location:
  • Phone: 323-295-4555
  • Fax: 323-508-0150
Mailing address:
  • Phone: 323-841-6853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number50388
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: