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General NPI Number Information
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NPI Number | 1073610796
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Entity Type | Individual
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Provider Name | KIMBERLY KAY WISDORF-HOUTKOOPER PH.D.
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Gender | Female
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Dates
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Enumeration Date | 09/17/2006
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Last Update Date | 07/20/2023
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Provider Practice Location Address
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Address Line | 71 S 20TH ST STE 209
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City | BATTLE CREEK
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State | MI
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Zip | 49015-2900
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Country | US
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Telephone | 269-501-0125
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Fax | 888-614-4010
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Provider Business Mailing Address
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Address Line | 5181 WALNUT RDG
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City | BATTLE CREEK
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State | MI
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Zip | 49017-9210
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Country | US
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Telephone | 269-501-0125
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Fax | 888-614-4010
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 6301009191
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6301009191
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License Number State | MI
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