Provider Demographics
NPI:1841946019
Name:QUALLICH, KRISTINE MICHELLE (PHD)
Entity type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:MICHELLE
Last Name:QUALLICH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4080 PRESERVE RUN CIR
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-6431
Mailing Address - Country:US
Mailing Address - Phone:216-299-1889
Mailing Address - Fax:
Practice Address - Street 1:4080 PRESERVE RUN CIR
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-6431
Practice Address - Country:US
Practice Address - Phone:216-299-1889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-26
Last Update Date:2022-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6408103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist