Provider Demographics
NPI:1336576289
Name:REZNY, KRISTINE AMANDA
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:AMANDA
Last Name:REZNY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2558 S SEPULVEDA BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-3171
Mailing Address - Country:US
Mailing Address - Phone:630-935-8688
Mailing Address - Fax:
Practice Address - Street 1:4425 S JONES BLVD STE D3
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-3370
Practice Address - Country:US
Practice Address - Phone:702-991-3150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-08
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILR25050190795104100000X
CA1158761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1023324076Medicaid