Healthcare Provider Details

I. General information

NPI: 1154764371
Provider Name (Legal Business Name): DENISE BISBICOS KECK L.I.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVENUE
BOSTON MA
02215
US

IV. Provider business mailing address

769 VFW PKWY
WEST ROXBURY MA
02132-2406
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-1157
  • Fax:
Mailing address:
  • Phone: 617-967-3176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110349
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: