Provider Demographics
NPI:1497371413
Name:ISAAC, KRISTINE ISHA
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ISHA
Last Name:ISAAC
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 1:77 MATTAPAN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02126-3302
Mailing Address - Country:US
Mailing Address - Phone:857-237-4827
Mailing Address - Fax:
Practice Address - Street 1:77 MATTAPAN ST APT 2
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02126-3302
Practice Address - Country:US
Practice Address - Phone:857-237-4827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS65909763106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician