Provider Demographics
NPI:1114095270
Name:NUTTALL, KIM HELLAINE
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:HELLAINE
Last Name:NUTTALL
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KIM
Other - Middle Name:HELLANI
Other - Last Name:REDMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1010 MASSACHUSETTS AVENUE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:617-534-4212
Mailing Address - Fax:617-534-4221
Practice Address - Street 1:723 MASSACHUSETTS AVENUE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-534-4212
Practice Address - Fax:617-534-4221
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health