Provider Demographics
NPI:1447347133
Name:KINNIBURGH, KRISTINE M (LICSW)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:KINNIBURGH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 CANTON ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-1806
Mailing Address - Country:US
Mailing Address - Phone:857-939-8030
Mailing Address - Fax:
Practice Address - Street 1:1269 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5245
Practice Address - Country:US
Practice Address - Phone:617-232-1303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1112201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical