Provider Demographics
NPI:1093244147
Name:KRISTY M DONALDSON
Entity type:Organization
Organization Name:KRISTY M DONALDSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-725-8062
Mailing Address - Street 1:3500 HILLCREST DR STE 8
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-3144
Mailing Address - Country:US
Mailing Address - Phone:254-262-3506
Mailing Address - Fax:254-262-3506
Practice Address - Street 1:3500 HILLCREST DR STE 8
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3144
Practice Address - Country:US
Practice Address - Phone:254-262-3506
Practice Address - Fax:254-262-3506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-11
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63523101YP2500X, 101YM0800X
103TC1900X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX376990301Medicaid