Provider Demographics
NPI:1255007217
Name:WIERENGA, KATELYN RICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:RICHELLE
Last Name:WIERENGA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2531 S 73RD DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-1588
Mailing Address - Country:US
Mailing Address - Phone:602-561-4984
Mailing Address - Fax:
Practice Address - Street 1:2531 S 73RD DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-1588
Practice Address - Country:US
Practice Address - Phone:602-561-4984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-222141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLMSW-19606OtherSTATE OF ARIZONA BOARD OF BEHAVIORAL HEALTH EXAMINERS