Healthcare Provider Details

I. General information

NPI: 1376193110
Provider Name (Legal Business Name): KATHERINE ELIZABETH WILEY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 ALLEGHENY STREET
BOSTON MA
02120
US

IV. Provider business mailing address

71 ALLEGHANY ST
BOSTON MA
02120-3338
US

V. Phone/Fax

Practice location:
  • Phone: 617-254-0964
  • Fax:
Mailing address:
  • Phone: 617-254-0964
  • Fax: 617-254-5539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number000226777
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW126930
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: