Provider Demographics
NPI:1053320523
Name:KISNER-BOTHWELL, CAROL HELEN (AUD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:HELEN
Last Name:KISNER-BOTHWELL
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:HELEN
Other - Last Name:KISNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 NEEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1615
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:617-630-0141
Practice Address - Street 1:1 PRESTIGE DR
Practice Address - Street 2:SUITE 107
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-7164
Practice Address - Country:US
Practice Address - Phone:203-639-0311
Practice Address - Fax:203-639-1489
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000203231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT730000203CT04OtherBLUE CROSS BLUE SHIELD