Provider Demographics
NPI:1487703914
Name:VAN ZEYL, KRISTA KORY (MFT)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:KORY
Last Name:VAN ZEYL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-0125
Mailing Address - Country:US
Mailing Address - Phone:707-580-8597
Mailing Address - Fax:
Practice Address - Street 1:1111 HOWE AVE STE 390
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-8543
Practice Address - Country:US
Practice Address - Phone:916-531-6996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50885390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA115834OtherCALIFORNIA BOARD OF BEHAVIORAL SCIENCES LICENSE