Provider Demographics
NPI:1659303451
Name:KRISKIE, JUDITH (LCSW)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:KRISKIE
Suffix:
Gender:F
Credentials:LCSW
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 45
Mailing Address - Street 2:613 MCKNIGHT STREET
Mailing Address - City:GORDON
Mailing Address - State:PA
Mailing Address - Zip Code:17936-0045
Mailing Address - Country:US
Mailing Address - Phone:570-875-4103
Mailing Address - Fax:
Practice Address - Street 1:16 SOUTH CENTRE STREET
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901
Practice Address - Country:US
Practice Address - Phone:570-628-5234
Practice Address - Fax:570-628-9051
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0129631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102328162 0001Medicaid
PA102328162 0001Medicaid