Provider Demographics
NPI:1942394416
Name:WOODWARD, KATHLEEN D (LICSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:D
Last Name:WOODWARD
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 1:58 PAULSON ROAD
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-1028
Mailing Address - Country:US
Mailing Address - Phone:617-969-8131
Mailing Address - Fax:617-969-8131
Practice Address - Street 1:58 PAULSON ROAD
Practice Address - Street 2:
Practice Address - City:WABAN
Practice Address - State:MA
Practice Address - Zip Code:02468-1028
Practice Address - Country:US
Practice Address - Phone:617-969-8131
Practice Address - Fax:617-969-8131
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1020611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO1160OtherBLUE CROSS/BLUE SHIELD
MA076274OtherVALUE OPTIONS
MAPO1160Medicare ID - Type Unspecified