Provider Demographics
NPI:1588990378
Name:FORTNER, KRYSTAL D (LCSW)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:D
Last Name:FORTNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 BAYSIDE CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-7461
Mailing Address - Country:US
Mailing Address - Phone:415-845-8416
Mailing Address - Fax:
Practice Address - Street 1:214 BAYSIDE CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-7461
Practice Address - Country:US
Practice Address - Phone:415-845-8416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2023-08-16
Deactivation Date:2013-08-29
Deactivation Code:
Reactivation Date:2023-08-11
Provider Licenses
StateLicense IDTaxonomies
CALCS 260191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical