Healthcare Provider Details

I. General information

NPI: 1194746206
Provider Name (Legal Business Name): LAWRENCE J CIVALE LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W SQUANTUM ST SUITE 21
QUINCY MA
02171-2122
US

IV. Provider business mailing address

27 HANSON ST
BOSTON MA
02118-3603
US

V. Phone/Fax

Practice location:
  • Phone: 617-947-3261
  • Fax: 617-451-0803
Mailing address:
  • Phone: 617-947-3261
  • Fax: 617-451-0803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 110606-1
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: