1346517513 NPI number — MRS. KRISTINA KAYE WIERSEMA LMSW

Table of content: MRS. KRISTINA KAYE WIERSEMA LMSW (NPI 1346517513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346517513 NPI number — MRS. KRISTINA KAYE WIERSEMA LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIERSEMA
Provider First Name:
KRISTINA
Provider Middle Name:
KAYE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIERSEMA
Provider Other First Name:
KRISTY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1346517513
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13554 S HIGH POINT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49684-5534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-714-0292
Provider Business Mailing Address Fax Number:
231-714-0292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 W ELEVENTH ST STE 218
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49684-3289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-714-0292
Provider Business Practice Location Address Fax Number:
231-714-0292
Provider Enumeration Date:
11/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801093573 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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