Provider Demographics
NPI:1194344770
Name:RICHARD, KRISTINA MARTA
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:MARTA
Last Name:RICHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KRISTINA
Other - Middle Name:MARTA
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 908
Mailing Address - Street 2:
Mailing Address - City:HOLLOMAN AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88330-0908
Mailing Address - Country:US
Mailing Address - Phone:210-912-9505
Mailing Address - Fax:
Practice Address - Street 1:100 CREWS AVE APT A28
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-4497
Practice Address - Country:US
Practice Address - Phone:210-912-9505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician