Provider Demographics
NPI:1497880116
Name:KRIETSCH, KELLY (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KRIETSCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 W UNIVERSITY AVE
Mailing Address - Street 2:SUITE #202
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-2994
Mailing Address - Country:US
Mailing Address - Phone:928-779-4286
Mailing Address - Fax:928-774-1148
Practice Address - Street 1:2935 SOUTHWEST DR
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-3797
Practice Address - Country:US
Practice Address - Phone:928-203-4844
Practice Address - Fax:928-203-4497
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1554103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ12364601Medicaid
AZAZ0614590OtherBCBS
AZ64203Medicare ID - Type Unspecified
AZAZ0614590OtherBCBS
AZ83612Medicare ID - Type Unspecified