Provider Demographics
NPI:1013689645
Name:PARKS, KRISTINA JOSEPHINE (CDCA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:JOSEPHINE
Last Name:PARKS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12705 EMERY AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-2247
Mailing Address - Country:US
Mailing Address - Phone:216-269-9803
Mailing Address - Fax:
Practice Address - Street 1:1400 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-1304
Practice Address - Country:US
Practice Address - Phone:216-391-6672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.176450101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)