Provider Demographics
NPI:1629054002
Name:KAVADLO, AMY S (LICSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:KAVADLO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1093 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-2100
Mailing Address - Country:US
Mailing Address - Phone:781-963-7775
Mailing Address - Fax:781-963-7776
Practice Address - Street 1:1093 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-2100
Practice Address - Country:US
Practice Address - Phone:781-963-7775
Practice Address - Fax:781-963-7776
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104863104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP04679Medicare ID - Type Unspecified