Provider Demographics
NPI:1699863944
Name:WALL, KRYSTEN (LMSW)
Entity type:Individual
Prefix:
First Name:KRYSTEN
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 HOGBACK RD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9736
Mailing Address - Country:US
Mailing Address - Phone:734-395-3433
Mailing Address - Fax:
Practice Address - Street 1:2002 HOGBACK RD
Practice Address - Street 2:SUITE 15
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9736
Practice Address - Country:US
Practice Address - Phone:734-395-3433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009415041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001733839OtherBC/BS
WV290040OtherANTHEM BC/BS
WV3810002567Medicaid
WV290040OtherANTHEM BC/CS
WV481428OtherVALUE OPTIONS
WV7379889OtherAETNA
WV290040OtherANTHEM BC/CS
WV481428OtherVALUE OPTIONS
WV7379889OtherAETNA