Provider Demographics
NPI:1184785644
Name:REARDON, KATHLEEN M (PHD, MSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:REARDON
Suffix:
Gender:F
Credentials:PHD, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SHAKER RD
Mailing Address - Street 2:STE 216
Mailing Address - City:SHIRLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01464-2525
Mailing Address - Country:US
Mailing Address - Phone:978-425-6666
Mailing Address - Fax:978-425-6777
Practice Address - Street 1:2 SHAKER RD
Practice Address - Street 2:STE D216
Practice Address - City:SHIRLEY
Practice Address - State:MA
Practice Address - Zip Code:01464-2561
Practice Address - Country:US
Practice Address - Phone:978-425-6666
Practice Address - Fax:978-425-6777
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2017-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA1015561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P21209Medicare ID - Type Unspecified
MAP01612Medicare UPIN