MEDICARE: KATHLEEN M CREHAN LISCW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	208	MA
2	104100000X	Social Worker	1032771	MA

General Provider Information

NPI Number	:	1154586626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN M CREHAN LISCW

Provider Business Mailing Address
First Line	:	965 MASSACHUSETTS AVE
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02118-2613
Country	:	US
Telephone Number	:	857-294-1051
Fax Number	:

Provider Business Practice Location Address
First Line	:	170 MORTON ST
Second Line	:	11 NORTH
City	:	JAMAICA PLAIN
State	:	MA
Zip	:	02130-3735
Country	:	US
Telephone Number	:	857-294-1051
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2008
Last Update Date	:	07/24/2008

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