Provider Demographics
NPI:1689254047
Name:WALENCZYK, KRISTIE MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIE
Middle Name:MARIE
Last Name:WALENCZYK
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 1:50 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:CENTERBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06409-1032
Mailing Address - Country:US
Mailing Address - Phone:301-385-4579
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-10
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003912103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical