Basic Information
| Provider Information | |||||||||
| NPI: | 1992061014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLBERT | ||||||||
| FirstName: | KRISTIE | ||||||||
| MiddleName: | MINCY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARQUEZ | ||||||||
| OtherFirstName: | KRISTIE | ||||||||
| OtherMiddleName: | MINCY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 HANCOCK STREET | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486024224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897973400 | ||||||||
| FaxNumber: | 9897990206 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 HANCOCK STREET | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486024224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897973400 | ||||||||
| FaxNumber: | 9897990206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2012 | ||||||||
| LastUpdateDate: | 11/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801096890 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.