Healthcare Provider Details

I. General information

NPI: 1609974666
Provider Name (Legal Business Name): ALLYN ST. LIFER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 UNION ST SUITE 319B
NEWTON CENTRE MA
02459-2244
US

IV. Provider business mailing address

75 GARLAND RD
NEWTON CENTRE MA
02459-1741
US

V. Phone/Fax

Practice location:
  • Phone: 617-527-5004
  • Fax: 617-527-4727
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1021709
License Number StateMA

VII. Legacy identifiers

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

# 1
IdentifierP06386
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBSMA
# 2
Identifier732286
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerTUFTS HEALTH PLAN
# 3
Identifier104688
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerMAGELLAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: