Healthcare Provider Details

I. General information

NPI: 1396018024
Provider Name (Legal Business Name): KRISTINA WILKERSON QMHA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 HEALTH SERVICES DR C/O FAMILY SERVICE AGENCY OF DEKALB COUNTY
DEKALB IL
60115-9637
US

IV. Provider business mailing address

1009 ASPEN CT APT 7
DEKALB IL
60115-6523
US

V. Phone/Fax

Practice location:
  • Phone: 815-758-8616
  • Fax: 815-758-8159
Mailing address:
  • Phone: 702-517-0309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1602498500
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178012552
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: