Provider Demographics
NPI:1336171156
Name:SUGRUE, KATHLEEN (LMHC, CADAC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SUGRUE
Suffix:
Gender:F
Credentials:LMHC, CADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 COLBY RD
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-7919
Mailing Address - Country:US
Mailing Address - Phone:617-842-4311
Mailing Address - Fax:617-325-1317
Practice Address - Street 1:1674 BEACON ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-2148
Practice Address - Country:US
Practice Address - Phone:617-842-4311
Practice Address - Fax:617-325-1317
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4744101YM0800X
MA0937 AD101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALM0754OtherBLUE CROSS BLUE SHIELD