Healthcare Provider Details

I. General information

NPI: 1790793768
Provider Name (Legal Business Name): JEFFREY ERIC THOMAS LICSW LICENSED INDEP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 BEACON STREET #5
BROOKLINE MA
02446
US

IV. Provider business mailing address

31 GRANVILLE ROAD #1
CAMBRIDGE MA
02138
US

V. Phone/Fax

Practice location:
  • Phone: 617-739-1619
  • Fax: 617-383-6210
Mailing address:
  • Phone: 617-739-1619
  • Fax: 617-383-6210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1016680
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: