Provider Demographics
NPI:1245550797
Name:ANDERSON, KRISTIN MARIE (PHD, LCP)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 EXECUTIVE PL
Mailing Address - Street 2:SUITE #404
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-3807
Mailing Address - Country:US
Mailing Address - Phone:630-631-2180
Mailing Address - Fax:
Practice Address - Street 1:1250 EXECUTIVE PL
Practice Address - Street 2:SUITE #404
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-3807
Practice Address - Country:US
Practice Address - Phone:630-631-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-07
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.006406103T00000X, 103TC0700X, 103TC1900X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy