1487029336 NPI number — MRS. KRISTIN NICOLE FEARON LCSW

Table of content: MRS. KRISTIN NICOLE FEARON LCSW (NPI 1487029336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487029336 NPI number — MRS. KRISTIN NICOLE FEARON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEARON
Provider First Name:
KRISTIN
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RESCH
Provider Other First Name:
KRISTIN
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487029336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1088
Provider Second Line Business Mailing Address:
105 VENTURE WAY
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59632-1088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-225-4610
Provider Business Mailing Address Fax Number:
406-225-3464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 VENTURE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-225-4610
Provider Business Practice Location Address Fax Number:
406-225-3464
Provider Enumeration Date:
12/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SWP-LCSW-LIC-7559 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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