Provider Demographics
NPI:1538644539
Name:GEARHART, KRISTIN ELIZABETH
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:GEARHART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 E REPUBLIC RD STE D
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6588
Mailing Address - Country:US
Mailing Address - Phone:417-351-4282
Mailing Address - Fax:
Practice Address - Street 1:1717 E REPUBLIC RD STE D
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6588
Practice Address - Country:US
Practice Address - Phone:417-351-4282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016042477101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor