Basic Information
Provider Information | |||||||||
NPI: | 1801344254 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CROOYMANS | ||||||||
FirstName: | KRISTEN | ||||||||
MiddleName: | ALEA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MFTI | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 22053 JODI PL | ||||||||
Address2: |   | ||||||||
City: | SANTA CLARITA | ||||||||
State: | CA | ||||||||
PostalCode: | 913504307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 18250 ROSCOE BLVD STE 120 | ||||||||
Address2: |   | ||||||||
City: | NORTHRIDGE | ||||||||
State: | CA | ||||||||
PostalCode: | 913254265 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263939199 | ||||||||
FaxNumber: | 6612661210 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2016 | ||||||||
LastUpdateDate: | 01/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | LMFT104885 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 106H00000X | IMF88748 | CA | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 95-2633765 | 01 | CA | MEDI-CAL | OTHER |