Basic Information
Provider Information
NPI: 1003152257
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MULLINS
FirstName: KRISTAL
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: LPCC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 1080
Address2:  
City: BURKESVILLE
State: KY
PostalCode: 427171080
CountryCode: US
TelephoneNumber: 2708586655
FaxNumber: 2708584027
Practice Location
Address1: 75 COLLEGE ST
Address2:  
City: LIBERTY
State: KY
PostalCode: 425393271
CountryCode: US
TelephoneNumber: 8444350900
FaxNumber: 2708584029
Other Information
ProviderEnumerationDate: 12/17/2012
LastUpdateDate: 10/09/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500X104258KYY Behavioral Health & Social Service ProvidersCounselorProfessional

ID Information
IDTypeStateIssuerDescription
710028034005KY MEDICAID


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