Provider Demographics
NPI:1427196724
Name:STIDHAM, KRISTEN NICHOLE (BS MS)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICHOLE
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:BS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3696
Practice Address - Street 1:3169 2ND AVE E
Practice Address - Street 2:WCB # 3
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219
Practice Address - Country:US
Practice Address - Phone:276-523-8360
Practice Address - Fax:276-323-8362
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor