Provider Demographics
NPI:1518254614
Name:KRISTOVIC, MICHAEL JOSEPH (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:KRISTOVIC
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13058 S ESCANABA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60633-1709
Mailing Address - Country:US
Mailing Address - Phone:312-610-9552
Mailing Address - Fax:
Practice Address - Street 1:3322 N ASHLAND AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-0195
Practice Address - Country:US
Practice Address - Phone:312-610-9552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-09
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0137911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical