Provider Demographics
NPI:1861923393
Name:MAXWELL, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MAXWELL
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 1:18 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-2711
Mailing Address - Country:US
Mailing Address - Phone:617-365-2627
Mailing Address - Fax:
Practice Address - Street 1:66 CANAL ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2002
Practice Address - Country:US
Practice Address - Phone:617-788-1712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-26
Last Update Date:2017-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4871630101YM0800X
MA313985104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health