Provider Demographics
NPI:1649466681
Name:RUSSELL, KATHRYN BOAZ
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:BOAZ
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 BURLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1406
Mailing Address - Country:US
Mailing Address - Phone:817-761-5078
Mailing Address - Fax:781-275-7207
Practice Address - Street 1:205 BURLINGTON RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-1406
Practice Address - Country:US
Practice Address - Phone:817-761-5078
Practice Address - Fax:781-275-7207
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1004745OtherNHP
MAM18633OtherBCBS
MA0000023532OtherBMC
MA1004745OtherFALLON
MA042611055OtherTAX ID
MA1303287OtherMBHP
MA99618201OtherNETWORK HEALTH