Provider Demographics
NPI:1922894559
Name:RESPASS, KRISTEN VICTORIA RUTH
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:VICTORIA RUTH
Last Name:RESPASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:VICTORIA RUTH
Other - Last Name:CARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:557 WINGED ELM ST
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-7366
Mailing Address - Country:US
Mailing Address - Phone:641-414-7642
Mailing Address - Fax:
Practice Address - Street 1:800 LEGION ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4825
Practice Address - Country:US
Practice Address - Phone:843-516-0455
Practice Address - Fax:843-962-5277
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20991101YP2500X
SC10355101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
697962OtherCERTIFIED REHABILITATION COUNSELOR