Provider Demographics
NPI:1245615426
Name:MCDONALD, KRISTA MICHELLE (LSW)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:MICHELLE
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:HERNDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:220 E STATE ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1443
Mailing Address - Country:US
Mailing Address - Phone:618-402-4676
Mailing Address - Fax:
Practice Address - Street 1:220 E STATE ST STE 2A
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1443
Practice Address - Country:US
Practice Address - Phone:618-402-4676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0188601041C0700X
IL150.015484104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker