Provider Demographics
NPI:1053048124
Name:KISLYUK, NATASHA
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:KISLYUK
Suffix:
Gender:F
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 RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-3721
Mailing Address - Country:US
Mailing Address - Phone:413-335-4076
Mailing Address - Fax:
Practice Address - Street 1:67 S BEDFORD ST STE 101W
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-5152
Practice Address - Country:US
Practice Address - Phone:413-335-4076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3005103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst