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General NPI Number Information
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NPI Number | 1396018024
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Entity Type | Individual
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Provider Name | KRISTINA WILKERSON QMHA, LPC
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Gender | Female
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Dates
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Enumeration Date | 02/10/2012
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Last Update Date | 02/23/2017
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Provider Practice Location Address
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Address Line | 14 HEALTH SERVICES DR C/O FAMILY SERVICE AGENCY OF DEKALB COUNTY
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City | DEKALB
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State | IL
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Zip | 60115-9637
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Country | US
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Telephone | 815-758-8616
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Fax | 815-758-8159
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Provider Business Mailing Address
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Address Line | 1009 ASPEN CT APT 7
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City | DEKALB
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State | IL
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Zip | 60115-6523
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Country | US
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Telephone | 702-517-0309
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 1602498500
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License Number State | NV
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 178012552
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License Number State | IL
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