Healthcare Provider Details

I. General information

NPI: 1669452462
Provider Name (Legal Business Name): BONNIE NESSANBAUM LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 12/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1565 MAIN ST BLD.2 ROOM 206
TEWKSBURY MA
01876-2085
US

IV. Provider business mailing address

38 PICKNEY ST
SOMERVILLE MA
02145
US

V. Phone/Fax

Practice location:
  • Phone: 617-628-3555
  • Fax: 617-288-3910
Mailing address:
  • Phone: 617-628-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1016620
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: