Provider Demographics
NPI:1407730930
Name:FLEAGLE, KRISTIN NICOLE (EDM, LPC-ASSOCIATE)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICOLE
Last Name:FLEAGLE
Suffix:
Gender:F
Credentials:EDM, LPC-ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12000 FM 1171 APT 6307
Mailing Address - Street 2:
Mailing Address - City:NORTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-6022
Mailing Address - Country:US
Mailing Address - Phone:920-323-9561
Mailing Address - Fax:
Practice Address - Street 1:2451 EXECUTIVE DR STE 205
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-5606
Practice Address - Country:US
Practice Address - Phone:314-375-6599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX96422101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health