Provider Demographics
NPI:1033672100
Name:DR KERRIE LLC
Entity Type:Organization
Organization Name:DR KERRIE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONGENEELEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:617-372-5653
Mailing Address - Street 1:405 CONCORD AVE UNIT 386
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-7818
Mailing Address - Country:US
Mailing Address - Phone:617-372-5653
Mailing Address - Fax:
Practice Address - Street 1:10 HAWTHORNE PARK
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-2104
Practice Address - Country:US
Practice Address - Phone:617-372-5653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-07
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110138961Medicaid