Provider Demographics
NPI:1558971416
Name:BOHM, KRISTINA (LPC-IT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:BOHM
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N LYNNDALE DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-3041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 N LYNNDALE DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3041
Practice Address - Country:US
Practice Address - Phone:920-238-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4696226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional