Provider Demographics
NPI:1699313593
Name:BIRMINGHAM, KRISTEN (LADC)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:BIRMINGHAM
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 BARBARA LANE
Mailing Address - Street 2:
Mailing Address - City:PLANTSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06479
Mailing Address - Country:US
Mailing Address - Phone:860-919-4815
Mailing Address - Fax:877-346-8993
Practice Address - Street 1:276 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3022
Practice Address - Country:US
Practice Address - Phone:860-302-8671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 106H00000X
CT000033101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist