Provider Demographics
NPI:1871822098
Name:KINCHLA, MARK (PSYD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KINCHLA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 E CENTRAL ST STE 201
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-3644
Mailing Address - Country:US
Mailing Address - Phone:978-604-5561
Mailing Address - Fax:509-319-3307
Practice Address - Street 1:154 E CENTRAL ST STE 201
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760
Practice Address - Country:US
Practice Address - Phone:978-604-5561
Practice Address - Fax:509-319-3307
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-17
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10081103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1871822098OtherINDIVIDUAL NPI
MAI20150319000938Medicaid