Provider Demographics
NPI:1346746369
Name:WIERDA, KATHRYN (PHD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WIERDA
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 1:1045 76TH ST UNIT 3030
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-5913
Mailing Address - Country:US
Mailing Address - Phone:515-777-3388
Mailing Address - Fax:515-777-3387
Practice Address - Street 1:1045 76TH ST UNIT 3030
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-5913
Practice Address - Country:US
Practice Address - Phone:515-777-3388
Practice Address - Fax:515-777-3387
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA084157103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist