Provider Demographics
NPI:1366874844
Name:BIRCH, KRISTINA D (LPCC)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:D
Last Name:BIRCH
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:D
Other - Last Name:KOEHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APCC
Mailing Address - Street 1:1256 W LATHROP RD
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-9671
Mailing Address - Country:US
Mailing Address - Phone:209-426-0962
Mailing Address - Fax:
Practice Address - Street 1:1141 LEVER BLVD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-2855
Practice Address - Country:US
Practice Address - Phone:209-933-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CALPCC101YP2500X
CA6636101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor