Provider Demographics
NPI:1679912240
Name:BRENES, KRISTIAN W (MA)
Entity type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:W
Last Name:BRENES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16209 KAMANA RD STE 105
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1394
Mailing Address - Country:US
Mailing Address - Phone:760-515-7979
Mailing Address - Fax:
Practice Address - Street 1:16209 KAMANA RD STE 105
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1394
Practice Address - Country:US
Practice Address - Phone:760-515-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108617106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist