Provider Demographics
NPI:1043406333
Name:ROGENTINE-LEE, KRISTIN LOUISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:LOUISE
Last Name:ROGENTINE-LEE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3719 LATROBE DR
Mailing Address - Street 2:SUITE 830
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4861
Mailing Address - Country:US
Mailing Address - Phone:704-654-7088
Mailing Address - Fax:
Practice Address - Street 1:3719 LATROBE DR
Practice Address - Street 2:SUITE 830
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4861
Practice Address - Country:US
Practice Address - Phone:704-654-7088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2574103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000838Medicaid