Healthcare Provider Details

I. General information

NPI: 1508071887
Provider Name (Legal Business Name): KRISTEN STREET M.ED, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 BOREN BLVD
SEMINOLE OK
74868-2050
US

IV. Provider business mailing address

7913 HIGHWAY 270 BLDG A
HOLDENVILLE OK
74848-6416
US

V. Phone/Fax

Practice location:
  • Phone: 405-382-4507
  • Fax: 405-382-5269
Mailing address:
  • Phone: 405-360-2133
  • Fax: 405-360-2252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2892
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: