Basic Information
Provider Information | |||||||||
NPI: | 1053320523 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KISNER-BOTHWELL | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: | HELEN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | AUD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KISNER | ||||||||
OtherFirstName: | CAROL | ||||||||
OtherMiddleName: | HELEN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 25 NEEDHAM ST | ||||||||
Address2: |   | ||||||||
City: | NEWTON | ||||||||
State: | MA | ||||||||
PostalCode: | 024611615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6179646681 | ||||||||
FaxNumber: | 6176300141 | ||||||||
Practice Location | |||||||||
Address1: | 1 PRESTIGE DR | ||||||||
Address2: | SUITE 107 | ||||||||
City: | MERIDEN | ||||||||
State: | CT | ||||||||
PostalCode: | 064507164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2036390311 | ||||||||
FaxNumber: | 2036391489 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 000203 | CT | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
ID Information
ID | Type | State | Issuer | Description | 730000203CT04 | 01 | CT | BLUE CROSS BLUE SHIELD | OTHER |