=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841866423
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRISTIN BAILEY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2021
-----------------------------------------------------
Last Update Date | 06/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 PARK PL STE 11
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-1883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-954-1548
-----------------------------------------------------
Fax | 815-932-3663
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 PARK PL STE 11
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-1883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-954-1548
-----------------------------------------------------
Fax | 815-932-3663
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / THERAPIST
-----------------------------------------------------
Name | KRISTIN BAILEY
-----------------------------------------------------
Credential | LCSW, PMH-C
-----------------------------------------------------
Telephone | 815-954-1548
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------