Healthcare Provider Details

I. General information

NPI: 1336118223
Provider Name (Legal Business Name): NEIL DORE LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 CENTRE ST
WEST ROXBURY MA
02132
US

IV. Provider business mailing address

49A MORTON ST
JAMAICA PLAIN MA
02130
US

V. Phone/Fax

Practice location:
  • Phone: 617-325-6700
  • Fax: 617-325-6581
Mailing address:
  • Phone: 617-522-9189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number105696
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: