=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063989085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRISTEN IHDE, PSYD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2018
-----------------------------------------------------
Last Update Date | 12/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1212 HANCOCK ST STE 120D
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02169-4371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-241-3711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1212 HANCOCK ST STE 120D
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02169-4371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | KRISTEN IHDE
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 857-241-3711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------