Healthcare Provider Details

I. General information

NPI: 1255709473
Provider Name (Legal Business Name): KAE COLLURA LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 09/06/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 WARREN ST BLDG 9
BRIGHTON MA
02135-3601
US

IV. Provider business mailing address

79 PRINCETON ST
MEDFORD MA
02155-5944
US

V. Phone/Fax

Practice location:
  • Phone: 617-254-0964
  • Fax:
Mailing address:
  • Phone: 813-922-1783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: