Healthcare Provider Details

I. General information

NPI: 1790069060
Provider Name (Legal Business Name): KRISTINE LYNN KENT CERTIFIED ADDICTION
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 PHILLIPS ST SUITE A
STROUDSBURG PA
18360-2242
US

IV. Provider business mailing address

724 PHILLIPS ST SUITE A
STROUDSBURG PA
18360-2242
US

V. Phone/Fax

Practice location:
  • Phone: 570-517-0892
  • Fax: 570-476-6466
Mailing address:
  • Phone: 570-517-0892
  • Fax: 570-476-6466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3901
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: