Provider Demographics
NPI:1386770857
Name:KRIEG, CHARLENE KAY (PHD)
Entity type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:KAY
Last Name:KRIEG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5311 SUNCREST ROAD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92807-3717
Mailing Address - Country:US
Mailing Address - Phone:714-637-2319
Mailing Address - Fax:714-637-1108
Practice Address - Street 1:1401 N TUSTIN AVENUE
Practice Address - Street 2:SUITE 120
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705
Practice Address - Country:US
Practice Address - Phone:714-637-2319
Practice Address - Fax:714-637-1108
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13229103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9248127Medicaid
R16158Medicare UPIN
CA9248127Medicaid