Provider Demographics
NPI:1275971277
Name:NARDELLA, KATHLEEN A (LICSW, LCSW-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:NARDELLA
Suffix:
Gender:F
Credentials:LICSW, LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 BEACON ST # 255
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1822
Mailing Address - Country:US
Mailing Address - Phone:301-775-5373
Mailing Address - Fax:
Practice Address - Street 1:1056 BEACON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-1742
Practice Address - Country:US
Practice Address - Phone:301-775-5373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500799601041C0700X
MA1227571041C0700X
MD149951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD14995OtherCLINICAL SOCIAL WORK LICENSE
MA122757OtherCLINICAL SOCIAL WORK LICENSE
DCLC50079960OtherCLINICAL SOCIAL WORK LICENSE