Provider Demographics
NPI:1306034921
Name:WILTROUT, KRISTIN JO (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:JO
Last Name:WILTROUT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:JO
Other - Last Name:HODOUAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:311 JUDGES RD STE 4E
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-3655
Mailing Address - Country:US
Mailing Address - Phone:910-791-6767
Mailing Address - Fax:910-791-6890
Practice Address - Street 1:311 JUDGES RD STE 4E
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3655
Practice Address - Country:US
Practice Address - Phone:910-791-6767
Practice Address - Fax:910-791-6890
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2873103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical