Provider Demographics
NPI:1972168961
Name:SUMMERS, KRISTINA (SUDRC 9427)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:SUDRC 9427
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 ELMWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-2820
Mailing Address - Country:US
Mailing Address - Phone:805-714-7382
Mailing Address - Fax:
Practice Address - Street 1:604 W OCEAN AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6630
Practice Address - Country:US
Practice Address - Phone:805-736-0357
Practice Address - Fax:800-969-9350
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASUDRC9427101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9427OtherCADTP