=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174047138
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRISTIN PADERA MA LCPC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2017
-----------------------------------------------------
Last Update Date | 12/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1131 WHEATON OAKS CT
-----------------------------------------------------
City | WHEATON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60187-3181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-940-6828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1131 WHEATON OAKS CT
-----------------------------------------------------
City | WHEATON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60187-3181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-940-6828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KRISTIN GEORGIANNE PADERA
-----------------------------------------------------
Credential | MA LCPC
-----------------------------------------------------
Telephone | 630-940-9628
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 180.010302
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180.010302
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------