Basic Information
| Provider Information | |||||||||
| NPI: | 1649782707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IZEDI | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | VERONICA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAC DONALD | ||||||||
| OtherFirstName: | KRISTINE | ||||||||
| OtherMiddleName: | V | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4740 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917242005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268592089 | ||||||||
| FaxNumber: | 6268596537 | ||||||||
| Practice Location | |||||||||
| Address1: | 4740 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917242005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268592089 | ||||||||
| FaxNumber: | 6268596537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2017 | ||||||||
| LastUpdateDate: | 09/17/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF101512 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | AMFT101512 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.