Provider Demographics
NPI:1225686348
Name:GOTTILLA, KRYSTAL MARIE
Entity type:Individual
Prefix:DR
First Name:KRYSTAL
Middle Name:MARIE
Last Name:GOTTILLA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 BEDFORD ST STE 8
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-4438
Mailing Address - Country:US
Mailing Address - Phone:617-244-2700
Mailing Address - Fax:617-244-2774
Practice Address - Street 1:35 BEDFORD ST STE 12
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-4439
Practice Address - Country:US
Practice Address - Phone:339-224-4933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-02
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPSY10000684103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical