Provider Demographics
NPI:1407192859
Name:CHABOT, KRISTIN LEIGH (MFT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEIGH
Last Name:CHABOT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:LEIGH
Other - Last Name:GAULD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 RETREAT AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3309
Mailing Address - Country:US
Mailing Address - Phone:606-960-0208
Mailing Address - Fax:860-696-0030
Practice Address - Street 1:200 RETREAT AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3309
Practice Address - Country:US
Practice Address - Phone:860-696-0020
Practice Address - Fax:860-437-4552
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CT2460106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040564Medicaid