Provider Demographics
NPI:1881913705
Name:KIRK, KRISTIN (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:KIRK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 E QUEENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2985
Mailing Address - Country:US
Mailing Address - Phone:309-263-5565
Mailing Address - Fax:
Practice Address - Street 1:2001 W WILLOW KNOLLS DR STE 110
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1262
Practice Address - Country:US
Practice Address - Phone:309-692-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0122201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical