Provider Demographics
NPI:1588328165
Name:HERMON, KRISTAL M
Entity type:Individual
Prefix:
First Name:KRISTAL
Middle Name:M
Last Name:HERMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTAL
Other - Middle Name:M
Other - Last Name:BADGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 879229
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-9229
Mailing Address - Country:US
Mailing Address - Phone:907-715-6576
Mailing Address - Fax:
Practice Address - Street 1:7010 E BOGARD RD BLDG 2
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-4711
Practice Address - Country:US
Practice Address - Phone:907-373-4732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator