Healthcare Provider Details

I. General information

NPI: 1457579625
Provider Name (Legal Business Name): KRISTAN CAMERON MA., LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 LAKE ST
ANTIOCH IL
60002-1424
US

IV. Provider business mailing address

532 LAKE ST
ANTIOCH IL
60002-1424
US

V. Phone/Fax

Practice location:
  • Phone: 224-652-9085
  • Fax: 224-985-2116
Mailing address:
  • Phone: 224-652-9085
  • Fax: 224-985-2116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.002580
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: