Provider Demographics
NPI:1518390350
Name:WORTMAN, KRISTEN MARIE
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:MARIE
Last Name:WORTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 SANTA CLARA AVE STE 165
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-1333
Mailing Address - Country:US
Mailing Address - Phone:510-485-0008
Mailing Address - Fax:
Practice Address - Street 1:55 SANTA CLARA AVE STE 165
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-1333
Practice Address - Country:US
Practice Address - Phone:510-485-0008
Practice Address - Fax:510-485-0009
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31275103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist