Healthcare Provider Details

I. General information

NPI: 1225021033
Provider Name (Legal Business Name): KRISTIN L KREBS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103A SOUTH POINTE DRIVE
EDWARDSVILLE IL
62025-3780
US

IV. Provider business mailing address

PO BOX 790
EDWARDSVILLE IL
62025-0790
US

V. Phone/Fax

Practice location:
  • Phone: 618-656-2000
  • Fax: 618-656-1169
Mailing address:
  • Phone: 618-692-9640
  • Fax: 618-692-9643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149008998
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: