Provider Demographics
NPI:1750641940
Name:GORDIEJEW, KRISTIN (LMFT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:GORDIEJEW
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5090 SONOMA MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-8880
Mailing Address - Country:US
Mailing Address - Phone:707-696-1892
Mailing Address - Fax:
Practice Address - Street 1:2455 BENNETT VALLEY ROAD
Practice Address - Street 2:B201
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404
Practice Address - Country:US
Practice Address - Phone:707-520-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT87380106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist