Provider Demographics
NPI:1336400498
Name:WROCKLAGE, KRISTEN M (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:WROCKLAGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:M
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:50 GAYLORD FARM RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2828
Mailing Address - Country:US
Mailing Address - Phone:203-741-3343
Mailing Address - Fax:
Practice Address - Street 1:50 GAYLORD FARM RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2828
Practice Address - Country:US
Practice Address - Phone:203-741-3343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003174103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist