Provider Demographics
NPI:1619021789
Name:KRIVAK, KATHLEEN M (LIC AC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:KRIVAK
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 ATHELSTANE RD
Mailing Address - Street 2:APT. #2
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2419
Mailing Address - Country:US
Mailing Address - Phone:617-965-6440
Mailing Address - Fax:
Practice Address - Street 1:70 ATHELSTANE RD
Practice Address - Street 2:APT. #2
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-2419
Practice Address - Country:US
Practice Address - Phone:617-965-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219346171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist