Healthcare Provider Details

I. General information

NPI: 1164136099
Provider Name (Legal Business Name): KRISTY R SEARLES LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E TERRA COTTA AVE
CRYSTAL LAKE IL
60014-3649
US

IV. Provider business mailing address

11 MAPLE ST
CRYSTAL LAKE IL
60014-5916
US

V. Phone/Fax

Practice location:
  • Phone: 815-823-2803
  • Fax:
Mailing address:
  • Phone: 815-823-2803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.041167
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: