Basic Information
| Provider Information | |||||||||
| NPI: | 1184255960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITTS | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | LMSW, QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3005 NE DIAMOND LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974703609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414403532 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 270 W. GEROGIA AVE. | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083167955 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2020 | ||||||||
| LastUpdateDate: | 10/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 101YM0800X | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.