Provider Demographics
NPI:1215643564
Name:WEDDENDORF, KRISTIN LEE
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEE
Last Name:WEDDENDORF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 PARK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45410-1316
Mailing Address - Country:US
Mailing Address - Phone:405-664-2838
Mailing Address - Fax:
Practice Address - Street 1:4134 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-3043
Practice Address - Country:US
Practice Address - Phone:937-365-7455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1-24-78306103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst