Provider Demographics
NPI:1770221426
Name:CLOW, KRISTEN MICHELLE (MA, LCPC)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MICHELLE
Last Name:CLOW
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3548
Mailing Address - Country:US
Mailing Address - Phone:217-416-0737
Mailing Address - Fax:
Practice Address - Street 1:3233 MATHERS ROAD SUITE A
Practice Address - Street 2:
Practice Address - City:62711
Practice Address - State:IL
Practice Address - Zip Code:62704
Practice Address - Country:US
Practice Address - Phone:217-414-2064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
178.005177101YP2500X
IL178.005177101YP2500X
IL180.007516101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional