Provider Demographics
NPI:1659866465
Name:LIATSOS, KENNA LEE (LICSW, PHD)
Entity Type:Individual
Prefix:
First Name:KENNA
Middle Name:LEE
Last Name:LIATSOS
Suffix:
Gender:F
Credentials:LICSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:MA
Mailing Address - Zip Code:02370-2667
Mailing Address - Country:US
Mailing Address - Phone:781-878-6056
Mailing Address - Fax:
Practice Address - Street 1:198 SPRING ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:MA
Practice Address - Zip Code:02370-2667
Practice Address - Country:US
Practice Address - Phone:781-878-6056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1067891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical