Provider Demographics
NPI:1447672191
Name:O'DWYER, KRISTEN MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:O'DWYER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MARIE
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2305 HISTORIC DECATUR RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-6071
Mailing Address - Country:US
Mailing Address - Phone:248-891-6946
Mailing Address - Fax:
Practice Address - Street 1:2305 HISTORIC DECATUR RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106
Practice Address - Country:US
Practice Address - Phone:619-708-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010976551041C0700X
CA097731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90773OtherLCSW