Provider Demographics
NPI:1962979682
Name:FAJACK, KRISTEN N (LMFT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:N
Last Name:FAJACK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:N
Other - Last Name:GRATZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9058
Mailing Address - Country:US
Mailing Address - Phone:419-695-8010
Mailing Address - Fax:419-695-0004
Practice Address - Street 1:1169 EASTERN PKWY STE 3364
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1415
Practice Address - Country:US
Practice Address - Phone:502-813-8280
Practice Address - Fax:502-473-1334
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY245187106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100563620Medicaid