Healthcare Provider Details

I. General information

NPI: 1881161784
Provider Name (Legal Business Name): RAKESH H KHETARPAL LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 LINCOLN ST
ALLSTON MA
02134-1318
US

IV. Provider business mailing address

512 WASHINGTON ST APT 1
BRIGHTON MA
02135-2549
US

V. Phone/Fax

Practice location:
  • Phone: 617-763-2154
  • Fax:
Mailing address:
  • Phone: 857-869-3619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number121416
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: