Provider Demographics
NPI:1578815635
Name:TRAHAN, KRISTINA ANNE (MSW)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ANNE
Last Name:TRAHAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:ANNE
Other - Last Name:CORNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2316 CRANBERRY TER
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-1045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5270 NORTHLAND DR NE STE B
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1073
Practice Address - Country:US
Practice Address - Phone:616-915-4769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801097786104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker