Healthcare Provider Details

I. General information

NPI: 1871733204
Provider Name (Legal Business Name): WILFREDO JOSEF ESCOBAR LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 10/30/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 HAZELMERE RD
BOSTON MA
02131-1424
US

IV. Provider business mailing address

2 HAZELMERE RD
BOSTON MA
02131-1424
US

V. Phone/Fax

Practice location:
  • Phone: 617-678-7879
  • Fax:
Mailing address:
  • Phone: 617-669-9746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number347807
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1028760
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: