Provider Demographics
NPI:1043888514
Name:VICKERS, KATHLEEN ELAINE I
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELAINE
Last Name:VICKERS
Suffix:I
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 1:1005 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-3179
Mailing Address - Country:US
Mailing Address - Phone:160-347-5519
Mailing Address - Fax:
Practice Address - Street 1:1005 MAIN ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-3179
Practice Address - Country:US
Practice Address - Phone:160-347-5519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS90889172261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2HC9-X05-FV36Medicaid