Provider Demographics
NPI:1538673140
Name:YELLS, KRISTINE JOHANSSON (PHD, LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:JOHANSSON
Last Name:YELLS
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:JOHANSSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, LCSW
Mailing Address - Street 1:PO BOX 1326
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-1326
Mailing Address - Country:US
Mailing Address - Phone:903-927-3782
Mailing Address - Fax:903-927-1764
Practice Address - Street 1:1400 COLLEGE DR STE 204
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3575
Practice Address - Country:US
Practice Address - Phone:903-791-1110
Practice Address - Fax:903-791-9353
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8590-C104100000X
TX64902104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR8590-COtherLICENSE
TX64902OtherLICENSE