MEDICARE: COURTNEY GAVIN MSW

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	1041C0700X	Clinical Social Worker
2	1041C0700X	Clinical Social Worker	122587	MA

General Provider Information

NPI Number	:	1396193884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY GAVIN MSW

Provider Business Mailing Address
First Line	:	10 LYNE RD
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02135-4018
Country	:	US
Telephone Number	:	617-257-2237
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 LYNE RD
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02135-4018
Country	:	US
Telephone Number	:	617-257-2237
Fax Number	:

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

Provider Enumeration Date	:	05/25/2016
Last Update Date	:	07/23/2021

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