Provider Demographics
NPI:1093946857
Name:ETCHISON, KRISTA RENEE (MA, LCMHCS, NCC)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:RENEE
Last Name:ETCHISON
Suffix:
Gender:F
Credentials:MA, LCMHCS, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1764 HERITAGE CENTER DR STE 204
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4092
Mailing Address - Country:US
Mailing Address - Phone:984-235-7596
Mailing Address - Fax:984-235-7054
Practice Address - Street 1:1764 HERITAGE CENTER DR STE 202
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-4092
Practice Address - Country:US
Practice Address - Phone:984-235-7596
Practice Address - Fax:984-235-7054
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005227101YM0800X
NC10790101YM0800X, 101YP2500X
NCS10790101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional