Healthcare Provider Details

I. General information

NPI: 1497808869
Provider Name (Legal Business Name): GAIL FLACKETT LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 ORIENT AVENUE
NEWTON CENTRE MA
02459
US

IV. Provider business mailing address

20 ORIENT AVENUE
NEWTON CENTRE MA
02459
US

V. Phone/Fax

Practice location:
  • Phone: 617-527-1402
  • Fax: 617-928-0945
Mailing address:
  • Phone: 617-527-1402
  • Fax: 617-928-0945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100218
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: