Provider Demographics
NPI:1245359322
Name:KILLGORE, KRISTI DENISE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KRISTI
Middle Name:DENISE
Last Name:KILLGORE
Suffix:
Gender:F
Credentials:LCSW
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 221
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CA
Mailing Address - Zip Code:95386
Mailing Address - Country:US
Mailing Address - Phone:209-537-8078
Mailing Address - Fax:
Practice Address - Street 1:1904 RICHLAND AVE
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307
Practice Address - Country:US
Practice Address - Phone:209-558-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA801551041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical