Provider Demographics
NPI:1972642486
Name:KRISTOVICH, DONNA NONE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:NONE
Last Name:KRISTOVICH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:DONNA
Other - Middle Name:NONE
Other - Last Name:KRISTOVICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2014 VARDON LN
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1371
Mailing Address - Country:US
Mailing Address - Phone:708-798-9043
Mailing Address - Fax:
Practice Address - Street 1:9641 W. L53RD ST.
Practice Address - Street 2:SUITE 45
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3777
Practice Address - Country:US
Practice Address - Phone:708-873-0704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL303750Medicare ID - Type UnspecifiedCLINICAL SOCIAL WORKER