Provider Demographics
NPI:1366067951
Name:BRADA, KRISTIN JOY REYNOLDS
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:JOY REYNOLDS
Last Name:BRADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:JOY
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3020 CHILDREN'S WAY
Mailing Address - Street 2:MC 5100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-576-1700
Mailing Address - Fax:858-966-7573
Practice Address - Street 1:3020 CHILDREN'S WAY
Practice Address - Street 2:MC 5100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-576-1700
Practice Address - Fax:858-966-7573
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA276891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical