Provider Demographics
NPI:1295469658
Name:WANNQUIST, KRISTOPHER CHARLES LEE
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:CHARLES LEE
Last Name:WANNQUIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 SW 137TH ST
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1339
Mailing Address - Country:US
Mailing Address - Phone:425-624-6404
Mailing Address - Fax:
Practice Address - Street 1:1025 S 3RD ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2765
Practice Address - Country:US
Practice Address - Phone:206-624-6477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health