Healthcare Provider Details

I. General information

NPI: 1467526574
Provider Name (Legal Business Name): CLARE MARTINA LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 DIMOCK ST GODDARD BUILDING
ROXBURY MA
02119-1029
US

IV. Provider business mailing address

36A CRESCENT ST
WEST NEWTON MA
02465-2021
US

V. Phone/Fax

Practice location:
  • Phone: 617-442-8800
  • Fax: 617-541-8622
Mailing address:
  • Phone: 617-558-0081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3254
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: