Provider Demographics
NPI:1710979984
Name:KIM, KRISTIN CROMWELL (PSYD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:CROMWELL
Last Name:KIM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 N HICKORY LN
Mailing Address - Street 2:ROGERS MEMORIAL HOSPITAL
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4532
Mailing Address - Country:US
Mailing Address - Phone:262-646-1338
Mailing Address - Fax:262-646-7067
Practice Address - Street 1:11101 W LINCOLN AVE
Practice Address - Street 2:ROGERS MEMORIAL HOSPITAL
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1133
Practice Address - Country:US
Practice Address - Phone:414-327-3000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2405103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43578100Medicaid