Provider Demographics
NPI:1841231917
Name:HALLETT, KRISTINA MARIE (PHD, ABPP)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:HALLETT
Suffix:
Gender:F
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 BURBANK AVE
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-1459
Mailing Address - Country:US
Mailing Address - Phone:860-965-1655
Mailing Address - Fax:
Practice Address - Street 1:880 BURBANK AVE
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078-1459
Practice Address - Country:US
Practice Address - Phone:860-965-1655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6905103TC0700X
CT002493103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05752OtherBLUE CROSS
CT002493OtherLICENSE
MAW50652Medicaid