Provider Demographics
NPI:1467445114
Name:KISTLER, LAWRENCE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:M
Last Name:KISTLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-2520
Mailing Address - Country:US
Mailing Address - Phone:781-455-6336
Mailing Address - Fax:
Practice Address - Street 1:105 CHESTNUT ST STE 31
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-2520
Practice Address - Country:US
Practice Address - Phone:781-455-6336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2691103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW02857OtherBLUE CROSS BLUE SHIELD
MA138864OtherMAGELLAN
MA101288OtherMANAGED HEALTH NETWORK
MA101288OtherMANAGED HEALTH NETWORK