Provider Demographics
NPI:1053452599
Name:KINNEY, KRISTI RAE (LCPC)
Entity type:Individual
Prefix:MRS
First Name:KRISTI
Middle Name:RAE
Last Name:KINNEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14989 N PARK RD
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401
Mailing Address - Country:US
Mailing Address - Phone:217-868-5862
Mailing Address - Fax:217-868-5739
Practice Address - Street 1:14989 N PARK RD
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-7723
Practice Address - Country:US
Practice Address - Phone:217-868-5862
Practice Address - Fax:217-868-5739
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-003504101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180-003504OtherLCPC