Provider Demographics
NPI:1396215653
Name:CLEMENZ, KRISTIN BURGE (MS)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:BURGE
Last Name:CLEMENZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:BURGE
Other - Last Name:CULP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:225 E CHICAGO AVE # 30
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-4817
Mailing Address - Fax:312-227-9757
Practice Address - Street 1:225 E CHICAGO AVE # 30
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-4817
Practice Address - Fax:312-227-9757
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246000031170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS