Provider Demographics
NPI:1588337901
Name:ENDICOTT, KRISTINA LYNN (LPC)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LYNN
Last Name:ENDICOTT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:LYNN
Other - Last Name:MATNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:2694 STONE COAL RD
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 COURT HOUSE LN
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228
Practice Address - Country:US
Practice Address - Phone:276-219-3237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010360101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional