Provider Demographics
NPI:1235949397
Name:CLAYTON, KRISTINE (LSW)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:311 W DEPOT ST STE M
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-1500
Mailing Address - Country:US
Mailing Address - Phone:331-725-1190
Mailing Address - Fax:
Practice Address - Street 1:311 W DEPOT ST STE M
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-1500
Practice Address - Country:US
Practice Address - Phone:331-725-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.107213104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker