Provider Demographics
NPI:1841804366
Name:WAYT, KRISTINA L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:L
Last Name:WAYT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KRISTINA
Other - Middle Name:L
Other - Last Name:WAYT GONZALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-0856
Mailing Address - Country:US
Mailing Address - Phone:847-903-5604
Mailing Address - Fax:224-788-5112
Practice Address - Street 1:11310 HURON ST
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-3046
Practice Address - Country:US
Practice Address - Phone:303-450-7435
Practice Address - Fax:303-450-7436
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO09926811104100000X, 1041C0700X
COCSW.099268111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000187411Medicaid