Provider Demographics
NPI:1295589414
Name:WUERTZ, KRYSTA N
Entity type:Individual
Prefix:
First Name:KRYSTA
Middle Name:N
Last Name:WUERTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRYSTA
Other - Middle Name:NICOLE
Other - Last Name:RIFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1085 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-8312
Mailing Address - Country:US
Mailing Address - Phone:740-815-0841
Mailing Address - Fax:
Practice Address - Street 1:106 STARRET ST STE 100
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3993
Practice Address - Country:US
Practice Address - Phone:740-417-9265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program