Provider Demographics
NPI:1851939870
Name:MARANDA, KATHLEEN FITZGERALD (MS)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:FITZGERALD
Last Name:MARANDA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:FITZGERALD
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:418 NOANK RD
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2324
Mailing Address - Country:US
Mailing Address - Phone:860-501-2657
Mailing Address - Fax:
Practice Address - Street 1:85A DENISON AVE
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2710
Practice Address - Country:US
Practice Address - Phone:860-501-2657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004002101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional