Healthcare Provider Details

I. General information

NPI: 1235436171
Provider Name (Legal Business Name): CHARLOTTE BAILLIEUL CNP, RN, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 CENTRE ST
JAMAICA PLAIN MA
02130
US

IV. Provider business mailing address

42 8TH ST APT 2110
CHARLESTOWN MA
02129-4217
US

V. Phone/Fax

Practice location:
  • Phone: 617-645-5249
  • Fax:
Mailing address:
  • Phone: 617-645-5249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number118396
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN2312255
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2312255
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: