Provider Demographics
NPI:1093953341
Name:WALGREN, KRISTY LYNN (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:LYNN
Last Name:WALGREN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 EDGEHILL RD N
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1885
Mailing Address - Country:US
Mailing Address - Phone:704-355-0784
Mailing Address - Fax:704-446-1298
Practice Address - Street 1:1010 EDGEHILL RD N
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1885
Practice Address - Country:US
Practice Address - Phone:704-355-0784
Practice Address - Fax:704-446-1298
Is Sole Proprietor?:No
Enumeration Date:2009-01-24
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0064501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2853488OtherMEDICARE PROVIDER SUPPLIER PTAN
NC12065089OtherCAQH PROVIDER