Provider Demographics
NPI:1053494286
Name:DARDECK, KATHRYN (EDD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:
Last Name:DARDECK
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 DERBY ST STE 20
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-4051
Mailing Address - Country:US
Mailing Address - Phone:781-361-3390
Mailing Address - Fax:
Practice Address - Street 1:175 DERBY ST STE 20
Practice Address - Street 2:
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-4051
Practice Address - Country:US
Practice Address - Phone:781-361-3390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4449103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2034137OtherCIGNA
MA6101039OtherEVERCARE PROVIDER NUMBER
MAW04342OtherBCBS PROVIDER NUMBER
MA2034137OtherCIGNA