Provider Demographics
NPI:1295875011
Name:MUNN, KATHERINE TRACY (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:TRACY
Last Name:MUNN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:K.
Other - Middle Name:TRACY
Other - Last Name:MUNN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1 FITCHBURG ST
Mailing Address - Street 2:#C410
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-2136
Mailing Address - Country:US
Mailing Address - Phone:617-764-1886
Mailing Address - Fax:
Practice Address - Street 1:1 FITCHBURG ST
Practice Address - Street 2:#C410
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-2136
Practice Address - Country:US
Practice Address - Phone:617-764-1886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6007103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04826OtherBCBSMA PROVIDER ID