Healthcare Provider Details

I. General information

NPI: 1043992696
Provider Name (Legal Business Name): MRS. KRISTIN MICHELLE BESWICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS KRISTIN MICHELLE DIDAS

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 08/03/2023
Certification Date: 07/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 SUNSET TERRACE EXT
DERBY LINE VT
05830-8701
US

IV. Provider business mailing address

28 SUNSET TERRACE EXT
DERBY LINE VT
05830-8701
US

V. Phone/Fax

Practice location:
  • Phone: 602-316-2426
  • Fax:
Mailing address:
  • Phone: 602-316-2426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number8023040
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: