Provider Demographics
NPI:1124044375
Name:KALLIEL, KATHERINE MARY (EDD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:MARY
Last Name:KALLIEL
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-2320
Mailing Address - Country:US
Mailing Address - Phone:781-769-4233
Mailing Address - Fax:
Practice Address - Street 1:72 FULTON ST
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062
Practice Address - Country:US
Practice Address - Phone:781-769-4233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5091103T00000X, 103TH0100X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
W50178Medicare PIN