Provider Demographics
NPI:1568574788
Name:MACNAUGHTON RODRIGUE, KATHLEEN LEAH (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:LEAH
Last Name:MACNAUGHTON RODRIGUE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KATHLEEN
Other - Middle Name:LEAH
Other - Last Name:MACNAUGHTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 81083
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481
Mailing Address - Country:US
Mailing Address - Phone:617-206-8028
Mailing Address - Fax:
Practice Address - Street 1:486 WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482
Practice Address - Country:US
Practice Address - Phone:617-206-8028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPY8596103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54692Medicare ID - Type Unspecified