Basic Information
| Provider Information | |||||||||
| NPI: | 1053515270 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THEOFANIDES | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 86 ALDERBERRY LN | ||||||||
| Address2: | |||||||||
| City: | EAST FALMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025364805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085408417 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 543 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | NEW BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027402766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089845566 | ||||||||
| FaxNumber: | 5089945527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.