Provider Demographics
NPI:1275038614
Name:GRONDIN, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:GRONDIN
Suffix:
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 1:7 CAPTAIN JONES WAY
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02364-1155
Mailing Address - Country:US
Mailing Address - Phone:617-680-9751
Mailing Address - Fax:
Practice Address - Street 1:80 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1740
Practice Address - Country:US
Practice Address - Phone:781-290-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2020-05-25
Deactivation Date:2020-05-15
Deactivation Code:
Reactivation Date:2020-05-22
Provider Licenses
StateLicense IDTaxonomies
MA3052-MH-B1103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty