Provider Demographics
NPI:1245728583
Name:SUPTIC, KRISTINA M
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:M
Last Name:SUPTIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-4141
Mailing Address - Country:US
Mailing Address - Phone:304-929-0786
Mailing Address - Fax:304-929-2278
Practice Address - Street 1:330 N EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4141
Practice Address - Country:US
Practice Address - Phone:304-929-0786
Practice Address - Fax:304-929-2278
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP00940862101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)