MEDICARE: KRISTOFER R ANDERSON MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	45388	CA

General Provider Information

NPI Number	:	1245510353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTOFER R ANDERSON MFT

Provider Business Mailing Address
First Line	:	3200 E GUASTI RD
Second Line	:	SUITE 100-42
City	:	ONTARIO
State	:	CA
Zip	:	91761-8660
Country	:	US
Telephone Number	:	909-262-1768
Fax Number	:

Provider Business Practice Location Address
First Line	:	3200 E GUASTI RD
Second Line	:	SUITE 100-42
City	:	ONTARIO
State	:	CA
Zip	:	91761-8660
Country	:	US
Telephone Number	:	909-262-1768
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2011
Last Update Date	:	08/19/2011

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