Provider Demographics
NPI:1932975125
Name:CAMPBELL, KRISTA KAY
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:KAY
Last Name:CAMPBELL
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 1:1345 LAKEHILLS DR
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-3606
Mailing Address - Country:US
Mailing Address - Phone:530-676-4110
Mailing Address - Fax:
Practice Address - Street 1:768 PLEASANT VALLEY RD # 1
Practice Address - Street 2:
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9260
Practice Address - Country:US
Practice Address - Phone:530-621-6126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103290390200000X, 390200000X
CA154008101YM0800X
CA0000000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program