Provider Demographics
NPI:1164730024
Name:CALLAHAN, KATHLEEN ROSE (LICSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ROSE
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COREY ST APT 104
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-4674
Mailing Address - Country:US
Mailing Address - Phone:617-347-8210
Mailing Address - Fax:
Practice Address - Street 1:52 FORBES ST APT 2
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-1844
Practice Address - Country:US
Practice Address - Phone:617-291-3334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA413621104100000X
MA1231281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker