Provider Demographics
NPI:1225162076
Name:GERNON, KRISTIN LEA (LMSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEA
Last Name:GERNON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:LEA GERNON
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:4130 OAK ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-1615
Mailing Address - Country:US
Mailing Address - Phone:646-752-4054
Mailing Address - Fax:
Practice Address - Street 1:1223 MEADOWLARK LN
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-1258
Practice Address - Country:US
Practice Address - Phone:913-890-7567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6220104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098080AMedicaid
KS100098080COtherSED WAIVER
KS100098080AMedicaid
KS3620000Medicare ID - Type UnspecifiedMEDICARE PART B