=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184305922
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHIE DALUM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2023
-----------------------------------------------------
Last Update Date | 07/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 MELLEN ST FL 5
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02138-2757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-331-6331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4441 OLD COLLEGE RD APT 7103
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77801-3534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-739-4385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LMHC10000663
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------