Provider Demographics
NPI:1659315950
Name:VERBA, KRISTEN LYNN (LBSW)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LYNN
Last Name:VERBA
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:LYNN
Other - Last Name:PENEGOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LBSW
Mailing Address - Street 1:715 PYLE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4456
Mailing Address - Country:US
Mailing Address - Phone:906-774-0522
Mailing Address - Fax:906-774-1570
Practice Address - Street 1:401 10TH AVE
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-3009
Practice Address - Country:US
Practice Address - Phone:906-863-7841
Practice Address - Fax:906-863-2833
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802084825104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKV084825OtherBCBS OF MI