Provider Demographics
NPI:1316218902
Name:GAINES, KATONYA (MED)
Entity Type:Individual
Prefix:MS
First Name:KATONYA
Middle Name:
Last Name:GAINES
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 COBDEN ST
Mailing Address - Street 2:3
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1304
Mailing Address - Country:US
Mailing Address - Phone:617-216-7478
Mailing Address - Fax:
Practice Address - Street 1:40 COBDEN ST
Practice Address - Street 2:3
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1304
Practice Address - Country:US
Practice Address - Phone:617-216-7478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool