Provider Demographics
NPI:1548395478
Name:FLY, KRISTEN LEONARD (MFT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:LEONARD
Last Name:FLY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1540
Mailing Address - Country:US
Mailing Address - Phone:757-912-5359
Mailing Address - Fax:757-595-1885
Practice Address - Street 1:718 J CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1540
Practice Address - Country:US
Practice Address - Phone:757-912-5359
Practice Address - Fax:757-595-1885
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFTINTERN, IMF 49868106H00000X
VA0717001230106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist