Provider Demographics
NPI:1437355799
Name:KOETJE, KRISTIN LEIGH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:LEIGH
Last Name:KOETJE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 RUE DE LA LAVANDA
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89434
Mailing Address - Country:US
Mailing Address - Phone:775-502-7433
Mailing Address - Fax:863-314-9786
Practice Address - Street 1:310 RUE DE LA LAVANDA
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434
Practice Address - Country:US
Practice Address - Phone:775-502-7433
Practice Address - Fax:813-289-1091
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7907-C1041C0700X
FLSW76011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical