1952385395 NPI number — MS. KATHLEEN J DEZENZO LICSW

Table of content: MS. KATHLEEN J DEZENZO LICSW (NPI 1952385395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952385395 NPI number — MS. KATHLEEN J DEZENZO LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEZENZO
Provider First Name:
KATHLEEN
Provider Middle Name:
J
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952385395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 HALL DR
Provider Second Line Business Mailing Address:
STE 1
Provider Business Mailing Address City Name:
AMHERST
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01002-2778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-431-4077
Provider Business Mailing Address Fax Number:
413-774-7448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 HALL DR
Provider Second Line Business Practice Location Address:
AMHERST MEDICAL CENTER
Provider Business Practice Location Address City Name:
AMHERST
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01002-2751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-256-8561
Provider Business Practice Location Address Fax Number:
413-256-4412
Provider Enumeration Date:
11/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  106680 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P04647 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1293395 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 7337314 . This is a "AETNA US/HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2072422 . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 106680 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 28435 . This is a "HEALTH NEW ENGLAND" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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