Provider Demographics
NPI:1548778822
Name:DUCKELS, KRISTINA KAY
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:KAY
Last Name:DUCKELS
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 1:21621 KIRKLAND RD
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-3966
Mailing Address - Country:US
Mailing Address - Phone:217-851-5936
Mailing Address - Fax:
Practice Address - Street 1:21621 KIRKLAND RD
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-3966
Practice Address - Country:US
Practice Address - Phone:217-851-5936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-20
Last Update Date:2018-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency