Healthcare Provider Details

I. General information

NPI: 1114095270
Provider Name (Legal Business Name): MS. KIM HELLAINE NUTTALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. KIM HELLANI REDMON

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 MASSACHUSETTS AVENUE
BOSTON MA
02118
US

IV. Provider business mailing address

1010 MASSACHUSETTS AVENUE
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 617-534-4212
  • Fax: 617-534-4221
Mailing address:
  • Phone: 617-534-4212
  • Fax: 617-534-4221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: