Provider Demographics
NPI:1376217372
Name:KRISTOL, CASILLE PEARL
Entity Type:Individual
Prefix:
First Name:CASILLE
Middle Name:PEARL
Last Name:KRISTOL
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 1:4708 E LONE CACTUS DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-6160
Mailing Address - Country:US
Mailing Address - Phone:602-909-8049
Mailing Address - Fax:
Practice Address - Street 1:18205 N 51ST AVE STE 131
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1492
Practice Address - Country:US
Practice Address - Phone:602-499-5329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-18350101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health