Provider Demographics
NPI:1114412236
Name:GEORGIAN, KRISTINA
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:GEORGIAN
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 1:104 HARTFORD RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:CT
Mailing Address - Zip Code:06420-3841
Mailing Address - Country:US
Mailing Address - Phone:860-861-4373
Mailing Address - Fax:
Practice Address - Street 1:330 COLONEL LEDYARD HWY
Practice Address - Street 2:
Practice Address - City:LEDYARD
Practice Address - State:CT
Practice Address - Zip Code:06339-1910
Practice Address - Country:US
Practice Address - Phone:877-315-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-01
Last Update Date:2018-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician