Provider Demographics
NPI:1194095950
Name:BRENNFOERDER, KRISTA G (MA, LCPC)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:G
Last Name:BRENNFOERDER
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:G
Other - Last Name:SWENOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 E MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2287
Mailing Address - Country:US
Mailing Address - Phone:630-377-6613
Mailing Address - Fax:630-377-6225
Practice Address - Street 1:1120 E MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2287
Practice Address - Country:US
Practice Address - Phone:630-377-6613
Practice Address - Fax:630-377-6225
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009017307101Y00000X
IL180.008857101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor