Healthcare Provider Details

I. General information

NPI: 1518332238
Provider Name (Legal Business Name): KRYSTAL KUKA LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2015
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S 27TH ST
BILLINGS MT
59101-4227
US

IV. Provider business mailing address

123 S 27TH ST
BILLINGS MT
59101-4227
US

V. Phone/Fax

Practice location:
  • Phone: 406-247-3350
  • Fax: 406-247-3389
Mailing address:
  • Phone: 406-247-3220
  • Fax: 406-651-6406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBBH-LCPC-LIC-13217
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: