Provider Demographics
NPI:1720659378
Name:CAUDILL, KRYSTINA LYNN (LMSW)
Entity Type:Individual
Prefix:
First Name:KRYSTINA
Middle Name:LYNN
Last Name:CAUDILL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 N CAMPUS DR STE 200
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-6332
Mailing Address - Country:US
Mailing Address - Phone:620-794-2339
Mailing Address - Fax:785-271-6572
Practice Address - Street 1:816 N CAMPUS DR
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-6329
Practice Address - Country:US
Practice Address - Phone:620-794-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12187104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS12187OtherKSBSRB