Provider Demographics
NPI:1932686540
Name:MACDONALD, KATHY (LICSW)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 ARBORWAY
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2753
Mailing Address - Country:US
Mailing Address - Phone:617-435-0738
Mailing Address - Fax:
Practice Address - Street 1:75 ARBORWAY
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2753
Practice Address - Country:US
Practice Address - Phone:617-435-0738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10218701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1021870OtherLICSW