Provider Demographics
NPI:1285932277
Name:THEOBLAD, KATHRYN LOUISE (MED)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:LOUISE
Last Name:THEOBLAD
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 HINCKLEY RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-1625
Mailing Address - Country:US
Mailing Address - Phone:617-696-1497
Mailing Address - Fax:
Practice Address - Street 1:41 HINCKLEY RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-1625
Practice Address - Country:US
Practice Address - Phone:617-696-1497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA#1046101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA050330061-21OtherAARP