Provider Demographics
NPI:1508995127
Name:FREEARK-ZUCKER, KRISTINE ELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:ELLEN
Last Name:FREEARK-ZUCKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:FREEARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3525 DALEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9686
Mailing Address - Country:US
Mailing Address - Phone:734-668-0140
Mailing Address - Fax:734-995-1172
Practice Address - Street 1:916 FULLER ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-1215
Practice Address - Country:US
Practice Address - Phone:734-668-0140
Practice Address - Fax:734-995-1172
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002719103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11276437OtherCAQH PROVIDER ID
MI61-20013OtherPHPSM,UNITED HEALTHCARE
MI68-0-H1-4729-0OtherBCBS PROVIDER ID
MI0P29980Medicare ID - Type Unspecified