Healthcare Provider Details

I. General information

NPI: 1407331176
Provider Name (Legal Business Name): BONNIE YEZUKEVICH LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2018
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 CENTRE ST
WEST ROXBURY MA
02132-2513
US

IV. Provider business mailing address

117 N WORCESTER ST
NORTON MA
02766-2046
US

V. Phone/Fax

Practice location:
  • Phone: 617-694-5201
  • Fax:
Mailing address:
  • Phone: 617-694-5201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number115337
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: