Provider Demographics
NPI:1124847744
Name:MACCAUGHAN, KRISTINA MORIAH (ACMHC, ATR-P)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MORIAH
Last Name:MACCAUGHAN
Suffix:
Gender:F
Credentials:ACMHC, ATR-P
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:LEDEZMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 PARKVIEW TER
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5106
Mailing Address - Country:US
Mailing Address - Phone:616-550-3533
Mailing Address - Fax:
Practice Address - Street 1:940 E SOUTH UNION AVE
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2302
Practice Address - Country:US
Practice Address - Phone:385-346-0031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14086952-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health