Provider Demographics
NPI:1073610796
Name:WISDORF-HOUTKOOPER, KIMBERLY KAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:KAY
Last Name:WISDORF-HOUTKOOPER
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 1:5181 WALNUT RDG
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-9210
Mailing Address - Country:US
Mailing Address - Phone:269-501-0125
Mailing Address - Fax:888-614-4010
Practice Address - Street 1:71 S 20TH ST STE 209
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-2900
Practice Address - Country:US
Practice Address - Phone:269-501-0125
Practice Address - Fax:888-614-4010
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009191103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent