Provider Demographics
NPI:1043992696
Name:BESWICK, KRISTIN MICHELLE
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MICHELLE
Last Name:BESWICK
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:MICHELLE
Other - Last Name:DIDAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28 SUNSET TERRACE EXT
Mailing Address - Street 2:
Mailing Address - City:DERBY LINE
Mailing Address - State:VT
Mailing Address - Zip Code:05830-8701
Mailing Address - Country:US
Mailing Address - Phone:602-316-2426
Mailing Address - Fax:
Practice Address - Street 1:28 SUNSET TERRACE EXT
Practice Address - Street 2:
Practice Address - City:DERBY LINE
Practice Address - State:VT
Practice Address - Zip Code:05830-8701
Practice Address - Country:US
Practice Address - Phone:602-316-2426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT8023040103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool