Provider Demographics
NPI:1013423292
Name:OLIVER, KRISTIN (LMHC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:OLIVER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:LYNN
Other - Last Name:SHADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:580 DR KNAPP RD N
Mailing Address - Street 2:
Mailing Address - City:NEWARK VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:13811-3410
Mailing Address - Country:US
Mailing Address - Phone:607-725-4739
Mailing Address - Fax:
Practice Address - Street 1:580 DR KNAPP RD N
Practice Address - Street 2:
Practice Address - City:NEWARK VALLEY
Practice Address - State:NY
Practice Address - Zip Code:13811-3410
Practice Address - Country:US
Practice Address - Phone:607-725-4739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-24
Last Update Date:2017-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007468101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health