Provider Demographics
NPI:1649210865
Name:KRISTAL, FREDRIC A (PHD)
Entity Type:Individual
Prefix:
First Name:FREDRIC
Middle Name:A
Last Name:KRISTAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4909
Mailing Address - Country:US
Mailing Address - Phone:207-942-3816
Mailing Address - Fax:207-561-4725
Practice Address - Street 1:29 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4909
Practice Address - Country:US
Practice Address - Phone:207-942-3816
Practice Address - Fax:207-561-4725
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS925103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME223490099Medicaid
ME098303OtherANTHEM LEGACY NUMBER