Basic Information
| Provider Information | |||||||||
| NPI: | 1952385395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEZENZO | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31 HALL DR | ||||||||
| Address2: | STE 1 | ||||||||
| City: | AMHERST | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010022778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664314077 | ||||||||
| FaxNumber: | 4137747448 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 HALL DR | ||||||||
| Address2: | AMHERST MEDICAL CENTER | ||||||||
| City: | AMHERST | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010022751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132568561 | ||||||||
| FaxNumber: | 4132564412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 106680 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | P04647 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 1293395 | 01 | MA | FALLON | OTHER | 7337314 | 01 | MA | AETNA US/HEALTHCARE | OTHER | 2072422 | 01 | MA | CIGNA BEHAVIORAL HEALTH | OTHER | 106680 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 28435 | 01 | MA | HEALTH NEW ENGLAND | OTHER |