Provider Demographics
NPI:1427554443
Name:KATHRYN E. WIERDA, PH.D., PLLC
Entity Type:Organization
Organization Name:KATHRYN E. WIERDA, PH.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIERDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-777-3388
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
Practice Address - Country:US
Practice Address - Phone:515-777-3388
Practice Address - Fax:515-777-3387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-30
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA084157261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)