Healthcare Provider Details

I. General information

NPI: 1649210865
Provider Name (Legal Business Name): FREDRIC A KRISTAL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 FRANKLIN ST
BANGOR ME
04401-4909
US

IV. Provider business mailing address

29 FRANKLIN ST
BANGOR ME
04401-4909
US

V. Phone/Fax

Practice location:
  • Phone: 207-942-3816
  • Fax: 207-561-4725
Mailing address:
  • Phone: 207-942-3816
  • Fax: 207-561-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS925
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: