Provider Demographics
NPI:1528723376
Name:PHELAN, KRISTINE (AMFT)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:PHELAN
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3959
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-0395
Mailing Address - Country:US
Mailing Address - Phone:415-244-0971
Mailing Address - Fax:
Practice Address - Street 1:11175 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-2157
Practice Address - Country:US
Practice Address - Phone:510-559-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-06
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT128314106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist