Provider Demographics
NPI:1063045953
Name:KAUFMAN, KRISTEN M
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:KAUFMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 W MELROSE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3417
Mailing Address - Country:US
Mailing Address - Phone:410-598-9222
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD STE 404
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3418
Practice Address - Country:US
Practice Address - Phone:410-598-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012152101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.012152Other180.012152