Healthcare Provider Details

I. General information

NPI: 1942394416
Provider Name (Legal Business Name): KATHLEEN D. WOODWARD LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 PAULSON ROAD
WABAN MA
02468-1028
US

IV. Provider business mailing address

58 PAULSON ROAD
WABAN MA
02468-1028
US

V. Phone/Fax

Practice location:
  • Phone: 617-969-8131
  • Fax: 617-969-8131
Mailing address:
  • Phone: 617-969-8131
  • Fax: 617-969-8131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number102061
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: