Provider Demographics
NPI:1487029336
Name:FEARON, KRISTIN NICOLE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:NICOLE
Last Name:FEARON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:NICOLE
Other - Last Name:RESCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 1088
Mailing Address - Street 2:105 VENTURE WAY
Mailing Address - City:BOULDER
Mailing Address - State:MT
Mailing Address - Zip Code:59632-1088
Mailing Address - Country:US
Mailing Address - Phone:406-225-4610
Mailing Address - Fax:406-225-3464
Practice Address - Street 1:105 VENTURE WAY
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:MT
Practice Address - Zip Code:59632
Practice Address - Country:US
Practice Address - Phone:406-225-4610
Practice Address - Fax:406-225-3464
Is Sole Proprietor?:No
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSWP-LCSW-LIC-75591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical