Provider Demographics
NPI:1144525916
Name:FANT, KRISTINA JEANNE (LMHC, LPC)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:JEANNE
Last Name:FANT
Suffix:
Gender:F
Credentials:LMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 SW MARLOW AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5186
Mailing Address - Country:US
Mailing Address - Phone:360-828-8912
Mailing Address - Fax:503-292-5208
Practice Address - Street 1:406 SE 131ST AVE STE 303
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4014
Practice Address - Country:US
Practice Address - Phone:360-828-8912
Practice Address - Fax:503-292-5208
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60323715101Y00000X, 101YM0800X
WACP60294522101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)