Provider Demographics
NPI:1437202306
Name:WITHAM, KEVIN J (PHD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:WITHAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ALFRED ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1915
Mailing Address - Country:US
Mailing Address - Phone:781-646-0500
Mailing Address - Fax:781-646-7130
Practice Address - Street 1:12 ALFRED ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1915
Practice Address - Country:US
Practice Address - Phone:781-646-0500
Practice Address - Fax:781-646-7130
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8413103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA8413OtherLICENSE