MEDICARE: MISS CAITLIN M MCDONNELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1124397088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CAITLIN M MCDONNELL

Provider Business Mailing Address
First Line	:	19 MERCER ST APT 3
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02127-3911
Country	:	US
Telephone Number	:	585-269-9432
Fax Number	:

Provider Business Practice Location Address
First Line	:	675 MAIN ST
Second Line	:
City	:	WALTHAM
State	:	MA
Zip	:	02451-0602
Country	:	US
Telephone Number	:	781-893-2003
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2011
Last Update Date	:	12/22/2011

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