Provider Demographics
NPI:1023104254
Name:HERFKENS, KRISTINE MARIE (PHD)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MARIE
Last Name:HERFKENS
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 1:3310 CROASDAILE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-6806
Mailing Address - Country:US
Mailing Address - Phone:919-384-9682
Mailing Address - Fax:
Practice Address - Street 1:3310 CROASDAILE DR STE 400
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-6806
Practice Address - Country:US
Practice Address - Phone:919-384-9682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2192103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000514Medicaid
NC0376XOtherBLUE CROSS BLUE SHIELD
NC5648716OtherAETNA
NC5648716OtherAETNA
NC6000514Medicaid