Provider Demographics
NPI:1548735327
Name:KASANSULA, GLADYS NAKUNGU
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:NAKUNGU
Last Name:KASANSULA
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 1:24 WHITES AVE APT 27
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4323
Mailing Address - Country:US
Mailing Address - Phone:617-407-9385
Mailing Address - Fax:
Practice Address - Street 1:SQUARE MEDICAL GROUP
Practice Address - Street 2:124 WATERTOWN STREET, SUITE 2D
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472
Practice Address - Country:US
Practice Address - Phone:617-916-5069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health