Provider Demographics
NPI:1578172599
Name:MEDLEN, KRISTINE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:MEDLEN
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 1:2614 MARTINA DR APT 22
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-1166
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2378 WOODLAKE DR STE 280
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6016
Practice Address - Country:US
Practice Address - Phone:517-706-0421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI12041001103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst