Healthcare Provider Details

I. General information

NPI: 1811342710
Provider Name (Legal Business Name): KRISTEN S WELLENBROCK PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN S MILLER PSYD

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13908 SE STARK ST
PORTLAND OR
97233-2161
US

IV. Provider business mailing address

PO BOX 16308
PORTLAND OR
97292-0308
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-2343
  • Fax: 503-255-2344
Mailing address:
  • Phone: 503-255-2343
  • Fax: 503-255-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2665
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: