Provider Demographics
NPI:1336416635
Name:VESBACH, KRISTEN L (MS, LPC, ATR-L)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:L
Last Name:VESBACH
Suffix:
Gender:F
Credentials:MS, LPC, ATR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6692 FAIRWAY CIR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:WI
Mailing Address - Zip Code:53598-9740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2976 TRIVERTON PIKE DR
Practice Address - Street 2:SUITE 119
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-5840
Practice Address - Country:US
Practice Address - Phone:262-719-6569
Practice Address - Fax:608-286-1088
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI97-36101YM0800X
WI5219-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1336416635Medicaid