Provider Demographics
NPI:1902103161
Name:SIMON, KRISTINE JEAN (RN, LPC)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:JEAN
Last Name:SIMON
Suffix:
Gender:F
Credentials:RN, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 MCMAHON DR
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-3810
Mailing Address - Country:US
Mailing Address - Phone:608-212-5219
Mailing Address - Fax:
Practice Address - Street 1:330 S WHITNEY WAY
Practice Address - Street 2:SUITE NUMBER 303
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4638
Practice Address - Country:US
Practice Address - Phone:608-212-5219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4521-125101YP2500X
WI69991-030163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163WH1000XNursing Service ProvidersRegistered NurseHospice