Provider Demographics
NPI:1912614082
Name:CONKLIN, KRISTY JEAN (CAC-AD)
Entity Type:Individual
Prefix:MS
First Name:KRISTY
Middle Name:JEAN
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W HURON CT
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-2800
Mailing Address - Country:US
Mailing Address - Phone:443-806-4949
Mailing Address - Fax:
Practice Address - Street 1:422 NORTH ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5516
Practice Address - Country:US
Practice Address - Phone:444-806-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC2918101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)