Basic Information
| Provider Information | |||||||||
| NPI: | 1245900679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HART | ||||||||
| OtherFirstName: | KRISTEN | ||||||||
| OtherMiddleName: | ESSAYAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3031 S VERMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900073033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233732400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5054 S VERMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900372946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233732444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2021 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 106H00000X | 133259 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.