Provider Demographics
NPI:1932664455
Name:DEFORGE, KRISTLE (LMHC)
Entity Type:Individual
Prefix:
First Name:KRISTLE
Middle Name:
Last Name:DEFORGE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8A BUFFUM STREET EXT
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-2329
Mailing Address - Country:US
Mailing Address - Phone:603-520-8759
Mailing Address - Fax:
Practice Address - Street 1:100 CUMMINGS CTR STE 106B
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6105
Practice Address - Country:US
Practice Address - Phone:978-594-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10912101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health