Provider Demographics
NPI:1417118688
Name:KIRK, KRISTIN DESSERT (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:DESSERT
Last Name:KIRK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17247 GLASSFIELD DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5269
Mailing Address - Country:US
Mailing Address - Phone:704-237-0421
Mailing Address - Fax:704-705-2421
Practice Address - Street 1:903 NORTHEAST DR
Practice Address - Street 2:SUITE 101
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7416
Practice Address - Country:US
Practice Address - Phone:704-237-0421
Practice Address - Fax:704-705-2421
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0060571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2186760OtherCOMPSYCH
NC6106990Medicaid
NC1490AOtherBCBS
56162OtherMEDCOST
2186760OtherCOMPSYCH