Provider Demographics
NPI:1972165215
Name:WITHEM, KYRSTEN JAQUELYN (NONE)
Entity type:Individual
Prefix:
First Name:KYRSTEN
Middle Name:JAQUELYN
Last Name:WITHEM
Suffix:
Gender:F
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W ANDERSON LN # D202B
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-1132
Mailing Address - Country:US
Mailing Address - Phone:512-493-9755
Mailing Address - Fax:866-242-3803
Practice Address - Street 1:111 W ANDERSON LN # D202B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-1132
Practice Address - Country:US
Practice Address - Phone:512-493-9755
Practice Address - Fax:866-242-3803
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1790146942Medicaid