Provider Demographics
NPI:1790079994
Name:FRY, KATHLEEN M (PHD)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:M
Last Name:FRY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 E 11190 S
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-5329
Mailing Address - Country:US
Mailing Address - Phone:978-815-4800
Mailing Address - Fax:
Practice Address - Street 1:602 CARDINAL LN
Practice Address - Street 2:
Practice Address - City:TYNGSBORO
Practice Address - State:MA
Practice Address - Zip Code:01879-1583
Practice Address - Country:US
Practice Address - Phone:978-815-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0810007470103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program