Provider Demographics
NPI:1932704178
Name:CANTRELL, KRISTY RHYAN (PRSS-SUD)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:RHYAN
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:PRSS-SUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WASHINGTON AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3966
Mailing Address - Country:US
Mailing Address - Phone:304-792-8689
Mailing Address - Fax:304-744-8606
Practice Address - Street 1:20 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3452
Practice Address - Country:US
Practice Address - Phone:304-831-1101
Practice Address - Fax:304-831-1584
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
WV24-9177175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant