Healthcare Provider Details

I. General information

NPI: 1487055372
Provider Name (Legal Business Name): EVAN ANDREW MALKIEWICH LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOSTON MEDICAL CENTER
BOSTON MA
02118
US

IV. Provider business mailing address

241 MORELAND ST
WORCESTER MA
01609-1320
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-5245
  • Fax: 617-414-5520
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number122244
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: