MEDICARE: KRISTA RAE

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	157524	CA

General Provider Information

NPI Number	:	1902766728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTA RAE

Provider Business Mailing Address
First Line	:	PO BOX 1198
Second Line	:	#5542
City	:	SACRAMENTO
State	:	CA
Zip	:	95812
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4415 SONOMA HWY
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95409-7100
Country	:	US
Telephone Number	:	562-609-0385
Fax Number	:

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

Provider Enumeration Date	:	11/14/2025
Last Update Date	:	11/14/2025

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