Basic Information
| Provider Information | |||||||||
| NPI: | 1942245287 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLDWELL | ||||||||
| FirstName: | KRYSTIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5005 N PIEDRAS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799205001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155691382 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5005 N PIEDRAS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799205001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155691382 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 03/02/2011 | ||||||||
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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 | 103TC0700X | PY60143251 | WA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 184607 | 01 | KY | MEDICARE GROUP NUMBER | OTHER |