1275971277 NPI number — KATHLEEN A. NARDELLA LICSW, LCSW-C

Table of content: KATHLEEN A. NARDELLA LICSW, LCSW-C (NPI 1275971277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275971277 NPI number — KATHLEEN A. NARDELLA LICSW, LCSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NARDELLA
Provider First Name:
KATHLEEN
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW, LCSW-C
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:
1275971277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
831 BEACON ST # 255
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02459-1822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-775-5373
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1056 BEACON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02459-1742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-775-5373
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2013

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:  LC50079960 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 122757 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 14995 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14995 . This is a "CLINICAL SOCIAL WORK LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 122757 . This is a "CLINICAL SOCIAL WORK LICENSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: LC50079960 . This is a "CLINICAL SOCIAL WORK LICENSE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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