Provider Demographics
NPI:1205097763
Name:IVERSON, KATHERINE M (PHD)
Entity type:Individual
Prefix:MISS
First Name:KATHERINE
Middle Name:M
Last Name:IVERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KATHERINE
Other - Middle Name:M
Other - Last Name:IVERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:150 S HUNTINGTON AVE
Mailing Address - Street 2:116-B
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4817
Mailing Address - Country:US
Mailing Address - Phone:857-364-2112
Mailing Address - Fax:617-278-4501
Practice Address - Street 1:150 S HUNTINGTON AVE
Practice Address - Street 2:116-B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-4817
Practice Address - Country:US
Practice Address - Phone:857-364-2112
Practice Address - Fax:617-278-4501
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPSO 1187103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical