Provider Demographics
NPI:1811342710
Name:WELLENBROCK, KRISTEN S (PSYD)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:S
Last Name:WELLENBROCK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KRISTEN
Other - Middle Name:S
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 16308
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0308
Mailing Address - Country:US
Mailing Address - Phone:503-255-2343
Mailing Address - Fax:503-255-2344
Practice Address - Street 1:13908 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-2161
Practice Address - Country:US
Practice Address - Phone:503-255-2343
Practice Address - Fax:503-255-2344
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2665103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical