Provider Demographics
NPI:1174790968
Name:SMYLIE, KRISTINE ALICE (MA, MA, MFT)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ALICE
Last Name:SMYLIE
Suffix:
Gender:F
Credentials:MA, MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 HART AVE
Mailing Address - Street 2:#4
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3524
Mailing Address - Country:US
Mailing Address - Phone:319-463-3870
Mailing Address - Fax:
Practice Address - Street 1:22761 PACIFIC COAST HWY
Practice Address - Street 2:#232
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-5098
Practice Address - Country:US
Practice Address - Phone:310-463-3870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC28222101Y00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550010001050OtherUNITED BEHAVIOR HEALTH
CA550010001050OtherPACIFICARE BEHAVIORAL HEALTH