Basic Information
| Provider Information | |||||||||
| NPI: | 1730213315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALVAN | ||||||||
| FirstName: | KRISTINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17800 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923071221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602426336 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17800 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923071221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602426336 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 13312 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 13312 | 01 | CA | ACSW | OTHER |