Provider Demographics
NPI:1407743883
Name:DETHERAGE, KRISTINA ANN-MARIE
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:ANN-MARIE
Last Name:DETHERAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KRISTINA
Other - Middle Name:ANN-MARIE
Other - Last Name:BRAUCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4616 W MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45232-1710
Mailing Address - Country:US
Mailing Address - Phone:513-720-3430
Mailing Address - Fax:
Practice Address - Street 1:10400 BLACKLICK EASTERN RD
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-8235
Practice Address - Country:US
Practice Address - Phone:513-720-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-19
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator