Healthcare Provider Details

I. General information

NPI: 1720659378
Provider Name (Legal Business Name): KRYSTINA LYNN CAUDILL LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 N CAMPUS DR
GARDEN CITY KS
67846-6329
US

IV. Provider business mailing address

816 N CAMPUS DR STE 200
GARDEN CITY KS
67846-6332
US

V. Phone/Fax

Practice location:
  • Phone: 620-794-2339
  • Fax:
Mailing address:
  • Phone: 620-794-2339
  • Fax: 785-271-6572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12187
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: