Provider Demographics
NPI:1114226412
Name:CECALA, KATHARINE A
Entity type:Individual
Prefix:
First Name:KATHARINE
Middle Name:A
Last Name:CECALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHARINE
Other - Middle Name:A
Other - Last Name:BELMONT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:840 HARRISON AVE
Practice Address - Street 2:MENINO 4
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-414-4511
Practice Address - Fax:617-414-3171
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA258163208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110098859AMedicaid