Provider Demographics
NPI:1598143984
Name:AVANCE, KRISTIN (LMSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:AVANCE
Suffix:
Gender:F
Credentials:LMSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 E SHAWNEE CIR
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2528
Mailing Address - Country:US
Mailing Address - Phone:918-772-4004
Mailing Address - Fax:918-207-0424
Practice Address - Street 1:1277 SKILL CENTER CIR
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-6495
Practice Address - Country:US
Practice Address - Phone:918-772-4004
Practice Address - Fax:918-431-1173
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK62331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical