Basic Information
| Provider Information | |||||||||
| NPI: | 1437585296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRESON | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | ELISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW 80918 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAMOTA | ||||||||
| OtherFirstName: | KRISTINA | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 661 | ||||||||
| Address2: | |||||||||
| City: | PACIFICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940440661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508326900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 957 INDUSTRIAL RD STE B | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940704152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508326900 | ||||||||
| FaxNumber: | 6506209549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2013 | ||||||||
| LastUpdateDate: | 06/11/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | PPS | CA | N | Behavioral Health & Social Service Providers | Social Worker | School | 1041C0700X | 80918 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | 80918 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.