Healthcare Provider Details

I. General information

NPI: 1639818073
Provider Name (Legal Business Name): ALISA DELAGE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 DERBY ST STE 200
HINGHAM MA
02043-4216
US

IV. Provider business mailing address

PO BOX 835
BROCKTON MA
02303-0835
US

V. Phone/Fax

Practice location:
  • Phone: 508-203-1727
  • Fax:
Mailing address:
  • Phone: 508-203-1727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number124902
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: