1174047138 NPI number — KRISTIN PADERA MA LCPC INC.

Table of content: (NPI 1174047138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174047138 NPI number — KRISTIN PADERA MA LCPC INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KRISTIN PADERA MA LCPC INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174047138
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1131 WHEATON OAKS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHEATON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60187-3181
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-940-6828
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1131 WHEATON OAKS CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHEATON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60187-3181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-940-6828
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2017

Additional Information

Authorized Official

Authorized Official Last Name:
PADERA
Authorized Official First Name:
KRISTIN
Authorized Official Middle Name:
GEORGIANNE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
630-940-9628

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  180.010302 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 180.010302 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1700501962 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1902404650 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1932685732 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1023550282 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1114323359 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1528795739 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1962127019 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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