Healthcare Provider Details

I. General information

NPI: 1912483074
Provider Name (Legal Business Name): KRISTINA KOCHANOVA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N OAK AVE
MARSHFIELD WI
54449-5702
US

IV. Provider business mailing address

1000 N OAK AVE
MARSHFIELD WI
54449-5702
US

V. Phone/Fax

Practice location:
  • Phone: 715-387-5559
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5066
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number5066
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: