Provider Demographics
NPI:1508380932
Name:LONG, KRISTIN ANN (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANN
Last Name:LONG
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 1:13 EAGAN PL
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-5674
Mailing Address - Country:US
Mailing Address - Phone:610-349-4202
Mailing Address - Fax:
Practice Address - Street 1:124 HARVARD ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-6478
Practice Address - Country:US
Practice Address - Phone:610-349-4202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01422103TC0700X
MA10128103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical