Healthcare Provider Details

I. General information

NPI: 1134547276
Provider Name (Legal Business Name): KRISTIN WEBER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2014
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 MILLER PARK WAY
WEST MILWAUKEE WI
53214-3604
US

IV. Provider business mailing address

1610 MILLER PARK WAY
WEST MILWAUKEE WI
53214-3604
US

V. Phone/Fax

Practice location:
  • Phone: 414-672-3801
  • Fax: 414-672-6026
Mailing address:
  • Phone: 414-672-3801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17186-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5964-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: