Healthcare Provider Details

I. General information

NPI: 1659763498
Provider Name (Legal Business Name): KRISTEN KINNEAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 EDWARDS ST
ALTON IL
62002-3915
US

IV. Provider business mailing address

420 CHULA VISTA DR
BELLEVILLE IL
62221-3160
US

V. Phone/Fax

Practice location:
  • Phone: 618-462-2331
  • Fax: 618-462-2504
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: