Healthcare Provider Details

I. General information

NPI: 1205313616
Provider Name (Legal Business Name): KRISTINA REBELSKY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2018
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 IL ROUTE 2
DIXON IL
61021-9118
US

IV. Provider business mailing address

325 IL ROUTE 2
DIXON IL
61021-9118
US

V. Phone/Fax

Practice location:
  • Phone: 815-284-6611
  • Fax:
Mailing address:
  • Phone: 815-284-6611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149012642
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number072728
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: