Provider Demographics
NPI:1134558463
Name:WILMOTH, KRISTINE ELIZABETH (MS, LLP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ELIZABETH
Last Name:WILMOTH
Suffix:
Gender:F
Credentials:MS, LLP
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:ELIZABETH
Other - Last Name:WILMOTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:700 HAMMOND RD E STE 200
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-8641
Practice Address - Country:US
Practice Address - Phone:231-947-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014161103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical