Basic Information
| Provider Information | |||||||||
| NPI: | 1659098887 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAWKINS | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PLPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | UPCHURCH | ||||||||
| OtherFirstName: | KRISTINE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 402 S SILVER SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637037536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733341100 | ||||||||
| FaxNumber: | 5736514345 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 EL NATHAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARBLE HILL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637646376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732381027 | ||||||||
| FaxNumber: | 5732381171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2022 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 2022040476 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.