Healthcare Provider Details

I. General information

NPI: 1083589071
Provider Name (Legal Business Name): KRYSTAL CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2025
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CABOT RD STE 201
MEDFORD MA
02155-5173
US

IV. Provider business mailing address

10 CABOT RD STE 201
MEDFORD MA
02155-5173
US

V. Phone/Fax

Practice location:
  • Phone: 800-915-3211
  • Fax:
Mailing address:
  • Phone: 800-915-3211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN283093
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: