Provider Demographics
NPI:1194006239
Name:BONGARZONE, KACEY ROSE (MA, LMHC, ATR)
Entity Type:Individual
Prefix:MS
First Name:KACEY
Middle Name:ROSE
Last Name:BONGARZONE
Suffix:
Gender:F
Credentials:MA, LMHC, ATR
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 10
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-4028
Mailing Address - Country:US
Mailing Address - Phone:617-302-7814
Mailing Address - Fax:
Practice Address - Street 1:175 DERBY ST STE 10
Practice Address - Street 2:
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-4028
Practice Address - Country:US
Practice Address - Phone:617-302-7814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2019-06-10
Deactivation Date:2014-02-13
Deactivation Code:
Reactivation Date:2016-02-05
Provider Licenses
StateLicense IDTaxonomies
MA8811101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health