Healthcare Provider Details

I. General information

NPI: 1902994031
Provider Name (Legal Business Name): KRISTA DUCKETT LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 10/21/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 MDG UNIT 3215 RAMSTEIN AB
APO AE
09094-3215
US

IV. Provider business mailing address

PSC 2 BOX 10873
APO AE
09012-0109
US

V. Phone/Fax

Practice location:
  • Phone: 314-479-2390
  • Fax:
Mailing address:
  • Phone: 864-553-2009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI0600088
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: