Provider Demographics
NPI:1780293159
Name:DEJAEGHERE-TILLETT, KRISTINE M (LPC)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:DEJAEGHERE-TILLETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2528 S CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-4814
Mailing Address - Country:US
Mailing Address - Phone:605-881-8740
Mailing Address - Fax:
Practice Address - Street 1:2528 S CENTER AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4814
Practice Address - Country:US
Practice Address - Phone:605-881-8740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC20577101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health