Provider Demographics
NPI:1265823108
Name:MORGAN, KRISTIN RENEE (LICDC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:RENEE
Last Name:MORGAN
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8445 MUNSON RD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-2410
Mailing Address - Country:US
Mailing Address - Phone:440-205-1700
Mailing Address - Fax:440-205-2417
Practice Address - Street 1:1680 NAVE RD SE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-9604
Practice Address - Country:US
Practice Address - Phone:330-830-8740
Practice Address - Fax:330-830-0912
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-13
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161503101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2844093Medicaid