Provider Demographics
NPI:1073814067
Name:KRIVICKAS, KRISTIN MICHELLE (LCSW, CRADC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MICHELLE
Last Name:KRIVICKAS
Suffix:
Gender:F
Credentials:LCSW, CRADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 STEVENS CT
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-3532
Mailing Address - Country:US
Mailing Address - Phone:847-691-4840
Mailing Address - Fax:
Practice Address - Street 1:2215 14TH ST
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-1618
Practice Address - Country:US
Practice Address - Phone:847-984-5231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490152781041C0700X
IL30486101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IF APPLICABLEMedicare PIN
PHYSICIANS ONLYMedicare UPIN