Provider Demographics
NPI:1093080053
Name:BROTHERS, KRISTY LYNN
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LYNN
Last Name:BROTHERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SARATOGA VILLAGE BLVD
Mailing Address - Street 2:SUITE 35
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3737
Mailing Address - Country:US
Mailing Address - Phone:518-899-9235
Mailing Address - Fax:518-899-9315
Practice Address - Street 1:100 SARATOGA VILLAGE BLVD
Practice Address - Street 2:SUITE 35
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-3737
Practice Address - Country:US
Practice Address - Phone:518-899-9235
Practice Address - Fax:518-899-9315
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY623146103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool