Healthcare Provider Details

I. General information

NPI: 1053669903
Provider Name (Legal Business Name): KRISTI ANN WEAVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTI HALFOND LCPC

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 S ILLINOIS AVE
CARBONDALE IL
62903-5912
US

IV. Provider business mailing address

1190 GRAND OAK DR
CARBONDALE IL
62901-5474
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-6703
  • Fax: 618-549-3734
Mailing address:
  • Phone: 618-534-0607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180009792
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.009792
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: