Provider Demographics
NPI:1962989574
Name:BLEVINES, KATHERINE NOEL
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:NOEL
Last Name:BLEVINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 AUDUBON RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-2734
Mailing Address - Country:US
Mailing Address - Phone:617-676-5327
Mailing Address - Fax:
Practice Address - Street 1:459 BROADWAY
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4125
Practice Address - Country:US
Practice Address - Phone:617-349-6874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2120979101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool