Provider Demographics
NPI:1790564581
Name:PRISTAWA, KIMBERLY (NCSP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PRISTAWA
Suffix:
Gender:F
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 CAROL DR
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02830-1836
Mailing Address - Country:US
Mailing Address - Phone:401-226-5068
Mailing Address - Fax:
Practice Address - Street 1:425 EAST AVE
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:RI
Practice Address - Zip Code:02830-1506
Practice Address - Country:US
Practice Address - Phone:401-568-1310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI23852103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool