Healthcare Provider Details

I. General information

NPI: 1841660982
Provider Name (Legal Business Name): GOLSA MIRHOSSEINI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CONDOR ST HARBOR AREA EARLY CHILDHOOD SERVICES
EAST BOSTON MA
02128-1305
US

IV. Provider business mailing address

74 AVON ST APT. #1L
SOMERVILLE MA
02143-1625
US

V. Phone/Fax

Practice location:
  • Phone: 617-569-6560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number112794201
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: