Basic Information
Provider Information | |||||||||
NPI: | 1568834398 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KRISTI HOSEK, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6210 102ND ST | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794248284 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8064454190 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6500 QUAKER AVE | ||||||||
Address2: | SUITE D | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794135100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8064454190 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2015 | ||||||||
LastUpdateDate: | 10/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOSEK | ||||||||
AuthorizedOfficialFirstName: | KRISTI | ||||||||
AuthorizedOfficialMiddleName: | LYNN | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 8064454190 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LPC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 63479 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 1144558792 | 05 | TX |   | MEDICAID |