Provider Demographics
NPI:1346613817
Name:NAILLIEUX, KRISTINA MARIE
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:NAILLIEUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 E. HARRY STREET
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218
Mailing Address - Country:US
Mailing Address - Phone:316-831-0330
Mailing Address - Fax:316-837-9569
Practice Address - Street 1:4155 E HARRY ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-3725
Practice Address - Country:US
Practice Address - Phone:316-831-0330
Practice Address - Fax:316-837-9569
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2714106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS481030087Medicaid