Healthcare Provider Details

I. General information

NPI: 1124508544
Provider Name (Legal Business Name): STEPHANIE BECKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 MEDFORD ST
SOMERVILLE MA
02143-3421
US

IV. Provider business mailing address

61 MEDFORD ST
SOMERVILLE MA
02143-3421
US

V. Phone/Fax

Practice location:
  • Phone: 617-628-2601
  • Fax: 617-628-1085
Mailing address:
  • Phone: 617-628-2601
  • Fax: 617-628-1085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number117532
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: