Provider Demographics
NPI:1285102343
Name:SELF, KRISTIN (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 STONY LAKE DR APT 2B
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-6814
Mailing Address - Country:US
Mailing Address - Phone:757-771-9771
Mailing Address - Fax:
Practice Address - Street 1:2004 BREMO RD STE 201
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2442
Practice Address - Country:US
Practice Address - Phone:804-272-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040107141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical