Provider Demographics
NPI:1649243981
Name:EDEN, KATHRYN B (MSW LICSW)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:B
Last Name:EDEN
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 WAMPANOAG TRL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-1504
Mailing Address - Country:US
Mailing Address - Phone:401-435-7482
Mailing Address - Fax:
Practice Address - Street 1:610 WAMPANOAG TRAIL
Practice Address - Street 2:EAST BAY MENTAL HEALTH CENTER
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02915
Practice Address - Country:US
Practice Address - Phone:401-431-9870
Practice Address - Fax:401-435-7486
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI15W015251041C0700X
MA10218621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIKE54562Medicaid
RI413914OtherBLUE CHIP
RI32118-9OtherBCBSRI
RI62-75119OtherUNITED BEHAVIOR HEALTH
007057142Medicare PIN