1649747171 NPI number — KATHLEEN DUNFORD CICCHESE LICSW

Table of content: KATHLEEN DUNFORD CICCHESE LICSW (NPI 1649747171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649747171 NPI number — KATHLEEN DUNFORD CICCHESE LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUNFORD CICCHESE
Provider First Name:
KATHLEEN
Provider Middle Name:
Provider Name Prefix Text:
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:
1649747171
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 CONSTITUTION PLZ STE 140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTOWN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02129-2025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
578-408-4531
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HOME BASE
Provider Second Line Business Practice Location Address:
ONE CONSTITUTION WHARF, SUITE 140
Provider Business Practice Location Address City Name:
CHARLESTOWN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02129-0212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-724-7329
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2018

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:  223841 , 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)





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