Provider Demographics
NPI:1700514619
Name:CLINE, ISIAH FITZGERALD
Entity Type:Individual
Prefix:
First Name:ISIAH
Middle Name:FITZGERALD
Last Name:CLINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 KINGS WAY UNIT 102C
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-9006
Mailing Address - Country:US
Mailing Address - Phone:469-658-5607
Mailing Address - Fax:
Practice Address - Street 1:12 QUEEN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2411
Practice Address - Country:US
Practice Address - Phone:508-860-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor