Provider Demographics
NPI:1831180280
Name:BISTIS, KIMBERLY (PSYD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:BISTIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 COPELAND ST..
Mailing Address - Street 2:3F
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4030
Mailing Address - Country:US
Mailing Address - Phone:617-571-6688
Mailing Address - Fax:
Practice Address - Street 1:294 WASHINGTON ST.
Practice Address - Street 2:SUITE 415
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-4639
Practice Address - Country:US
Practice Address - Phone:617-571-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7480103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1859986Medicaid
MAW05968OtherBCBS MA
MAW05968OtherBCBS MA