Provider Demographics
NPI:1568701530
Name:RISTER, KRISTINE (LICSW-A, SUDP)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:RISTER
Suffix:
Gender:F
Credentials:LICSW-A, SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:360-353-9494
Mailing Address - Fax:360-353-9440
Practice Address - Street 1:922 FIR ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2525
Practice Address - Country:US
Practice Address - Phone:360-353-9422
Practice Address - Fax:360-353-9440
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60145336101YA0400X
WASC612345781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)