Provider Demographics
NPI:1821584822
Name:MCNEISH, KATHRYN CLARA
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CLARA
Last Name:MCNEISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-1700
Mailing Address - Country:US
Mailing Address - Phone:203-368-5515
Mailing Address - Fax:203-368-9167
Practice Address - Street 1:125 PENFIELD RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6611
Practice Address - Country:US
Practice Address - Phone:203-255-5777
Practice Address - Fax:203-368-9167
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004069985Medicaid