Provider Demographics
NPI:1568858371
Name:STEWART, KRYSTAL L (LPC)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:L
Last Name:STEWART
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5309
Mailing Address - Country:US
Mailing Address - Phone:815-332-6000
Mailing Address - Fax:815-332-6090
Practice Address - Street 1:8616 NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5309
Practice Address - Country:US
Practice Address - Phone:815-332-6000
Practice Address - Fax:815-332-6090
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.010827101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional