Provider Demographics
NPI:1447324801
Name:LISTON KRAFT, EDWARD (PHD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:LISTON KRAFT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:EDWARD
Other - Middle Name:E
Other - Last Name:LISTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 DELANO AVENUE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151
Mailing Address - Country:US
Mailing Address - Phone:617-983-7928
Mailing Address - Fax:617-983-7231
Practice Address - Street 1:1153 CENTRE STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130
Practice Address - Country:US
Practice Address - Phone:617-983-7928
Practice Address - Fax:617-983-7231
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW1043891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P02875Medicare ID - Type Unspecified