Provider Demographics
NPI:1285080663
Name:STACOM, KATHRYN (LICSW)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:
Last Name:STACOM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-2098
Mailing Address - Country:US
Mailing Address - Phone:781-431-1177
Mailing Address - Fax:781-431-1181
Practice Address - Street 1:11 RIVER ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-2098
Practice Address - Country:US
Practice Address - Phone:781-431-1177
Practice Address - Fax:781-431-1181
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1193911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical