Provider Demographics
NPI:1639849995
Name:IVAN, KRISTINA (MS, CGC)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:IVAN
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:HERMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CGC
Mailing Address - Street 1:22006 E 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-1482
Mailing Address - Country:US
Mailing Address - Phone:586-917-8015
Mailing Address - Fax:
Practice Address - Street 1:3577 W 13 MILE RD STE 140
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-551-5792
Practice Address - Fax:248-551-8437
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS