Provider Demographics
NPI:1912013251
Name:KLICKSTEIN, KATHRYN S (LICSW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:S
Last Name:KLICKSTEIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:SONN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:372 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-6202
Mailing Address - Country:US
Mailing Address - Phone:781-239-3550
Mailing Address - Fax:781-239-3272
Practice Address - Street 1:372 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-6202
Practice Address - Country:US
Practice Address - Phone:781-239-3550
Practice Address - Fax:781-239-3272
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1076691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA107669OtherTUFTS HEALTH PLAN
MAPO7144OtherBLUE CROSS OF MA
MAP20137Medicare ID - Type Unspecified