Provider Demographics
NPI:1972284925
Name:WOLTERS, TRISTAN
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:WOLTERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARION
Other - Middle Name:
Other - Last Name:WOLTERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5863 NW 72ND ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64151-1483
Mailing Address - Country:US
Mailing Address - Phone:816-984-8280
Mailing Address - Fax:
Practice Address - Street 1:1719 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-1124
Practice Address - Country:US
Practice Address - Phone:913-250-5634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS23-287300106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician