Basic Information
Provider Information | |||||||||
NPI: | 1992142673 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOSS | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSY.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MCDONALD | ||||||||
OtherFirstName: | KATHLEEN | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 175 E HAWTHORN PKWY STE 235 | ||||||||
Address2: |   | ||||||||
City: | VERNON HILLS | ||||||||
State: | IL | ||||||||
PostalCode: | 600611454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8477378768 | ||||||||
FaxNumber: | 8478595885 | ||||||||
Practice Location | |||||||||
Address1: | 1041 HIGHWAY 36 STE 206 | ||||||||
Address2: |   | ||||||||
City: | ATLANTIC HIGHLANDS | ||||||||
State: | NJ | ||||||||
PostalCode: | 07716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7329822888 | ||||||||
FaxNumber: | 8478595885 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2013 | ||||||||
LastUpdateDate: | 10/09/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0810004803 | VA | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 35SI00599100 | NJ | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.