Provider Demographics
NPI:1396018024
Name:WILKERSON, KRISTINA (QMHA, LPC)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:QMHA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 ASPEN CT
Mailing Address - Street 2:APT 7
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-6523
Mailing Address - Country:US
Mailing Address - Phone:702-517-0309
Mailing Address - Fax:
Practice Address - Street 1:14 HEALTH SERVICES DR
Practice Address - Street 2:C/O FAMILY SERVICE AGENCY OF DEKALB COUNTY
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9637
Practice Address - Country:US
Practice Address - Phone:815-758-8616
Practice Address - Fax:815-758-8159
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1602498500101YM0800X
IL178012552101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1602498500OtherSTATE
IL178012552OtherIDFPR