Healthcare Provider Details

I. General information

NPI: 1346797693
Provider Name (Legal Business Name): KRISTENA BRAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2016
Last Update Date: 09/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 TIMBERCREST DR
LOGANSPORT IN
46947-1355
US

IV. Provider business mailing address

1004 TIMBERCREST DR
LOGANSPORT IN
46947-1355
US

V. Phone/Fax

Practice location:
  • Phone: 190-216-8956
  • Fax:
Mailing address:
  • Phone: 190-216-8956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3444
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: