Provider Demographics
NPI:1518073683
Name:KITTSTEIN, CHRISTINA (LLC)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:KITTSTEIN
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10104 STATE ROUTE 4
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IL
Mailing Address - Zip Code:62254-2612
Mailing Address - Country:US
Mailing Address - Phone:618-979-7301
Mailing Address - Fax:
Practice Address - Street 1:6209 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-2015
Practice Address - Country:US
Practice Address - Phone:618-979-7301
Practice Address - Fax:888-972-8757
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL180-003952101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL551406OtherVALUE OPTIONS
IL06032112OtherBC/BS OF ILLINOIS
IL201674OtherBC/BS OF MISSOURI
IL7431733OtherAETNA