Provider Demographics
NPI:1598189474
Name:WOOTEN, KRISTIN (PC, CR, MA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:PC, CR, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7967 MILLWHEEL WAY
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-2016
Mailing Address - Country:US
Mailing Address - Phone:937-404-1084
Mailing Address - Fax:
Practice Address - Street 1:10979 REED HARTMAN HWY
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-2800
Practice Address - Country:US
Practice Address - Phone:937-404-1084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1300308101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health