=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104476902
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTIN BISHOP MACDERMOTT LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2019
-----------------------------------------------------
Last Update Date | 10/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 VILLAGE SQUARE XING STE 203
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-4531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-771-4550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 BERMUDA LAKE DR
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33418-4584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-309-5088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC0004736
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT102440
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 3950
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------