Provider Demographics
NPI:1346517513
Name:WIERSEMA, KRISTINA KAYE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:KAYE
Last Name:WIERSEMA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:
Other - Last Name:WIERSEMA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:13554 S HIGH POINT DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5534
Mailing Address - Country:US
Mailing Address - Phone:231-714-0292
Mailing Address - Fax:231-714-0292
Practice Address - Street 1:1200 W ELEVENTH ST STE 218
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3289
Practice Address - Country:US
Practice Address - Phone:231-714-0292
Practice Address - Fax:231-714-0292
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2016-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010935731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical