Healthcare Provider Details

I. General information

NPI: 1104214410
Provider Name (Legal Business Name): SOBHAN NAMVAR LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 MURPHY RD
NEEDHAM MA
02492-2110
US

IV. Provider business mailing address

19 MURPHY RD
NEEDHAM MA
02492-2110
US

V. Phone/Fax

Practice location:
  • Phone: 617-642-7274
  • Fax:
Mailing address:
  • Phone: 617-642-7274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW 118706
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierLICSW 118706
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBOARD OF SOCIAL WORK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: