Provider Demographics
NPI:1376864710
Name:SMITH, KRISTIN D (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:D
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:NEUROPSYCHOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5660
Mailing Address - Fax:414-259-9012
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:NEUROPSYCHOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5660
Practice Address - Fax:414-259-9012
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2873103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1376864710Medicaid
WI1376864710Medicaid