Healthcare Provider Details

I. General information

NPI: 1912357971
Provider Name (Legal Business Name): KIRSTEN WRIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 06/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N MAYFAIR RD
WAUWATOSA WI
53226-1309
US

IV. Provider business mailing address

4480 N 135TH ST
BROOKFIELD WI
53005-1224
US

V. Phone/Fax

Practice location:
  • Phone: 414-771-9304
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5716-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: