Provider Demographics
NPI:1164833760
Name:HORNBACK, KRISTINA (LAC)
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:
Last Name:HORNBACK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7020 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-7080
Mailing Address - Country:US
Mailing Address - Phone:605-693-3629
Mailing Address - Fax:605-693-1326
Practice Address - Street 1:7020 SUNSET RD
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-7080
Practice Address - Country:US
Practice Address - Phone:605-693-3629
Practice Address - Fax:605-693-1326
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD13101607101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)