Provider Demographics
NPI:1619125093
Name:WEGNER, KRISTIN MARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:MARY
Last Name:WEGNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 WARDEN ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-4960
Mailing Address - Country:US
Mailing Address - Phone:715-552-1620
Mailing Address - Fax:715-552-2734
Practice Address - Street 1:1802 WARDEN ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-4960
Practice Address - Country:US
Practice Address - Phone:715-552-1620
Practice Address - Fax:715-552-2734
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2675-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40984200Medicaid