Provider Demographics
NPI:1376676288
Name:KRISO, KEVIN (LPC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KRISO
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 LONG BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08008-3926
Mailing Address - Country:US
Mailing Address - Phone:609-494-1554
Mailing Address - Fax:609-361-9653
Practice Address - Street 1:4700 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08008-3926
Practice Address - Country:US
Practice Address - Phone:609-494-1554
Practice Address - Fax:609-361-9653
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00313800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0094251Medicaid