Provider Demographics
NPI:1902985138
Name:STURDEVANT, KRISTIN SUE (PHD LMHC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:SUE
Last Name:STURDEVANT
Suffix:
Gender:F
Credentials:PHD LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 S 1ST AVE.
Mailing Address - Street 2:STE F
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240
Mailing Address - Country:US
Mailing Address - Phone:319-354-4552
Mailing Address - Fax:319-512-4131
Practice Address - Street 1:700 S DUBUQUE ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-4202
Practice Address - Country:US
Practice Address - Phone:319-354-4552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00452101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA544261000IAMedicaid
IA544261000Medicaid