Provider Demographics
NPI:1912512690
Name:WICANDER, KRISTEN (MS)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:WICANDER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 PLEASANT VALLEY PKWY APT 2
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4211
Mailing Address - Country:US
Mailing Address - Phone:401-203-3068
Mailing Address - Fax:
Practice Address - Street 1:400 RESERVOIR AVE STE 2C
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-3595
Practice Address - Country:US
Practice Address - Phone:401-203-3068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC01703101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty