Provider Demographics
NPI:1497027643
Name:DEMIREV, KRISTIE (LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:DEMIREV
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:
Other - Last Name:ROSSETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:113 WEST ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887
Mailing Address - Country:US
Mailing Address - Phone:617-501-8312
Mailing Address - Fax:
Practice Address - Street 1:113 WEST ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887
Practice Address - Country:US
Practice Address - Phone:617-501-8312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216315104100000X
MA1171111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical