Provider Demographics
NPI:1619079399
Name:MEDBERY, KATHY (LPC)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:MEDBERY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BEECH MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1603
Mailing Address - Country:US
Mailing Address - Phone:860-423-8147
Mailing Address - Fax:860-423-8147
Practice Address - Street 1:50 BEECH MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1603
Practice Address - Country:US
Practice Address - Phone:860-423-8147
Practice Address - Fax:860-423-8147
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000213101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0007094313OtherAETNA
CT11243562OtherCAQH
CT240000213CT07OtherANTHEM