Healthcare Provider Details

I. General information

NPI: 1609090489
Provider Name (Legal Business Name): JOANNE T POMODORO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 COMMONWEALTH AVENUE
BOSTON MA
02215
US

IV. Provider business mailing address

683 BENNINGTON ST
EAST BOSTON MA
02128-1153
US

V. Phone/Fax

Practice location:
  • Phone: 617-585-7447
  • Fax:
Mailing address:
  • Phone: 617-413-2835
  • Fax: 617-262-2608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111467
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: