Provider Demographics
NPI:1336679455
Name:BUKALA, KRISTINE (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:BUKALA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25224 E EAMES ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410
Mailing Address - Country:US
Mailing Address - Phone:815-467-8181
Mailing Address - Fax:
Practice Address - Street 1:25224 W EAMES ST STE C
Practice Address - Street 2:
Practice Address - City:CHANNAHON
Practice Address - State:IL
Practice Address - Zip Code:60410-5256
Practice Address - Country:US
Practice Address - Phone:815-467-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490195651041C0700X
IL150015098104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker