Healthcare Provider Details

I. General information

NPI: 1073814067
Provider Name (Legal Business Name): KRISTIN MICHELLE KRIVICKAS LCSW, CRADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 14TH ST
NORTH CHICAGO IL
60064-1618
US

IV. Provider business mailing address

343 STEVENS CT
GRAYSLAKE IL
60030-3532
US

V. Phone/Fax

Practice location:
  • Phone: 847-984-5231
  • Fax:
Mailing address:
  • Phone: 847-691-4840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number30486
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149015278
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: