Provider Demographics
NPI:1700926086
Name:HENNESSY, KATHIE (PHD)
Entity Type:Individual
Prefix:
First Name:KATHIE
Middle Name:
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 MT. AUBURN ST.
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02476
Mailing Address - Country:US
Mailing Address - Phone:617-233-3828
Mailing Address - Fax:
Practice Address - Street 1:127 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5732
Practice Address - Country:US
Practice Address - Phone:617-233-3828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7914103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HE-W51526Medicare ID - Type UnspecifiedMEDICARE