Basic Information
| Provider Information | |||||||||
| NPI: | 1538673140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YELLS | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | JOHANSSON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D., LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHANSSON | ||||||||
| OtherFirstName: | KRISTINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D., LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1326 | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756711326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039273782 | ||||||||
| FaxNumber: | 9039271764 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 COLLEGE DR STE 204 | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755033575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037911110 | ||||||||
| FaxNumber: | 9037919353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2017 | ||||||||
| LastUpdateDate: | 11/20/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 8590-C | AR | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 64902 | TX | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 8590-C | 01 | AR | LICENSE | OTHER | 64902 | 01 | TX | LICENSE | OTHER |