Healthcare Provider Details

I. General information

NPI: 1477621647
Provider Name (Legal Business Name): DIANNE KILTY KRAAIJVANGER PSYD, LMHC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SOUTH AVE
NATICK MA
01760-4600
US

IV. Provider business mailing address

1 SOUTH AVE
NATICK MA
01760-4600
US

V. Phone/Fax

Practice location:
  • Phone: 781-705-2797
  • Fax:
Mailing address:
  • Phone: 781-705-2797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6124
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1308
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: