Healthcare Provider Details

I. General information

NPI: 1902394950
Provider Name (Legal Business Name): ALLISON LYN KIRSCHBAUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 SAINT SEBASTIAN WAY
AUGUSTA GA
30912-2613
US

IV. Provider business mailing address

4344 GIBSON AVE # B
SAINT LOUIS MO
63110-1612
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-6719
  • Fax:
Mailing address:
  • Phone: 415-637-5562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: