Provider Demographics
NPI:1225372709
Name:CHRISTODULU, KRISTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:
Last Name:CHRISTODULU
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3513
Mailing Address - Country:US
Mailing Address - Phone:518-442-2574
Mailing Address - Fax:
Practice Address - Street 1:1535 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3513
Practice Address - Country:US
Practice Address - Phone:518-442-2574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014998-1103TC0700X
MD03735103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical