Basic Information
| Provider Information | |||||||||
| NPI: | 1912202235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KWAK-REID | ||||||||
| FirstName: | KRISTELLE | ||||||||
| MiddleName: | MYUNG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KWAK-REID | ||||||||
| OtherFirstName: | KRIS, MYUNG | ||||||||
| OtherMiddleName: | HEE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12810 WOODLEY AVENUE | ||||||||
| Address2: | |||||||||
| City: | GRANADA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623015262 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6551 VAN NUYS BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914011442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189886335 | ||||||||
| FaxNumber: | 8189886817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2011 | ||||||||
| LastUpdateDate: | 01/18/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 27002 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.