Provider Demographics
NPI:1407297641
Name:SOMERVILLE, KRISTY (LMSW-CM)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:
Last Name:SOMERVILLE
Suffix:
Gender:F
Credentials:LMSW-CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6837 OAKLAND HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-8743
Mailing Address - Country:US
Mailing Address - Phone:989-614-0776
Mailing Address - Fax:
Practice Address - Street 1:685 E M 32 STE 211
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-7775
Practice Address - Country:US
Practice Address - Phone:989-614-0776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010797471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI115-N5Medicaid