Provider Demographics
NPI:1669099099
Name:SLATE, KRISTINA DIANE (LPC-S)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:DIANE
Last Name:SLATE
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:791 N HIGHWAY 77 STE 501C
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-1985
Mailing Address - Country:US
Mailing Address - Phone:469-337-0111
Mailing Address - Fax:
Practice Address - Street 1:147 WAGON WHEEL DR
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75167-4830
Practice Address - Country:US
Practice Address - Phone:469-337-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63609101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional