Basic Information
| Provider Information | |||||||||
| NPI: | 1588206403 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABISSO | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 MOUNT VERNON ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019703010 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11 CIRCLE AVE | ||||||||
| Address2: | |||||||||
| City: | LYNN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019053050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815952413 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2019 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | MA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 93897 | 01 | MA | ACADIA | OTHER |