Provider Demographics
NPI:1861894909
Name:PETTERSSON-ROSENBUSCH, KRISTINE KELLI (MA, LMFT)
Entity type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:KELLI
Last Name:PETTERSSON-ROSENBUSCH
Suffix:
Gender:F
Credentials:MA, LMFT
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 601
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549
Mailing Address - Country:US
Mailing Address - Phone:925-787-3834
Mailing Address - Fax:
Practice Address - Street 1:3490 BUSKIRK AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523
Practice Address - Country:US
Practice Address - Phone:925-787-3834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT39721106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist