Provider Demographics
NPI:1184255960
Name:FITTS, KRISTINE LYNN (LMSW, QMHP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:LYNN
Last Name:FITTS
Suffix:
Gender:F
Credentials:LMSW, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 NE DIAMOND LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3609
Mailing Address - Country:US
Mailing Address - Phone:541-440-3532
Mailing Address - Fax:
Practice Address - Street 1:270 W. GEROGIA AVE.
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-316-7955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2022-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker