Provider Demographics
NPI:1780175695
Name:STEPHENS, KRYSTEENA JOY (LAMFT)
Entity type:Individual
Prefix:
First Name:KRYSTEENA
Middle Name:JOY
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S ORCHARD ST STE 128
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1288
Mailing Address - Country:US
Mailing Address - Phone:208-817-0234
Mailing Address - Fax:
Practice Address - Street 1:410 S ORCHARD ST STE 128
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1288
Practice Address - Country:US
Practice Address - Phone:208-817-0234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2019-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLAMFT-6920106H00000X
IDLPC-7446101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLPC-7446OtherLICENSED PROFESSIONAL COUNSELOR NUMBER