Provider Demographics
NPI:1811015803
Name:MIKKELSEN, KRISTIN WHITNEY (MA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:WHITNEY
Last Name:MIKKELSEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:WHITNEY
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:29 SCARLETT ST
Mailing Address - Street 2:
Mailing Address - City:WEST BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01583-1618
Mailing Address - Country:US
Mailing Address - Phone:508-887-1608
Mailing Address - Fax:
Practice Address - Street 1:29 SCARLETT ST
Practice Address - Street 2:
Practice Address - City:WEST BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01583-1618
Practice Address - Country:US
Practice Address - Phone:508-887-1608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health