Healthcare Provider Details

I. General information

NPI: 1164551768
Provider Name (Legal Business Name): ALISSA SUSAN KUZNICK LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 HIGH ST DH7
MEDFORD MA
02155-3850
US

IV. Provider business mailing address

144 FULLER ST
WEST NEWTON MA
02465-2803
US

V. Phone/Fax

Practice location:
  • Phone: 781-393-8889
  • Fax: 781-396-3948
Mailing address:
  • Phone: 617-795-0248
  • Fax: 617-795-0263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110978
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: