Provider Demographics
NPI:1619245149
Name:CHARLESWORTH, KRISTIN J (PLPC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:J
Last Name:CHARLESWORTH
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:J
Other - Last Name:STRAUB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:107 WARD TER
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63019-1707
Mailing Address - Country:US
Mailing Address - Phone:314-546-5242
Mailing Address - Fax:
Practice Address - Street 1:107 WARD TER
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:MO
Practice Address - Zip Code:63019-1707
Practice Address - Country:US
Practice Address - Phone:314-546-5242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011039647101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional