Provider Demographics
NPI:1912520842
Name:WILLERT, KRISTIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:
Last Name:WILLERT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14044 CHESTNUT CT
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5873
Mailing Address - Country:US
Mailing Address - Phone:651-808-8688
Mailing Address - Fax:
Practice Address - Street 1:44075 PIPELINE PLZ STE 300
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5889
Practice Address - Country:US
Practice Address - Phone:815-793-3787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36042103TC0700X
MD06355103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical