Provider Demographics
NPI:1497819916
Name:THACKREY, KRISTINE MARIE (LISW, LICDC)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MARIE
Last Name:THACKREY
Suffix:
Gender:F
Credentials:LISW, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-3750
Mailing Address - Country:US
Mailing Address - Phone:419-999-2024
Mailing Address - Fax:419-999-2024
Practice Address - Street 1:3611 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-3750
Practice Address - Country:US
Practice Address - Phone:419-999-2024
Practice Address - Fax:419-999-2024
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH933608101YA0400X
OHI55221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000352379OtherANTHEM BLUE CROSS AND BLU