Provider Demographics
NPI:1124408554
Name:KING, KRISTAL J (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:J
Last Name:KING
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1644 W COLONIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:IL
Mailing Address - Zip Code:60067-1207
Mailing Address - Country:US
Mailing Address - Phone:847-776-4500
Mailing Address - Fax:847-776-4724
Practice Address - Street 1:1644 W COLONIAL PKWY
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:IL
Practice Address - Zip Code:60067-1207
Practice Address - Country:US
Practice Address - Phone:847-776-4500
Practice Address - Fax:847-776-4724
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490172831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical