Provider Demographics
NPI:1477372472
Name:AXE, KRISTINE A (PPC)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:A
Last Name:AXE
Suffix:
Gender:F
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 SPARKS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-6152
Mailing Address - Country:US
Mailing Address - Phone:307-369-4710
Mailing Address - Fax:307-222-0279
Practice Address - Street 1:3207 SPARKS RD STE 200
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-6152
Practice Address - Country:US
Practice Address - Phone:307-369-4710
Practice Address - Fax:307-222-0279
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1505101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health