Healthcare Provider Details

I. General information

NPI: 1881875789
Provider Name (Legal Business Name): SANDRA NEMIROFF LYONS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WILLOW ST
WEST ROXBURY MA
02132-1537
US

IV. Provider business mailing address

4 CAROLINA PL
JAMAICA PLAIN MA
02130-3211
US

V. Phone/Fax

Practice location:
  • Phone: 617-469-3080
  • Fax: 617-469-3085
Mailing address:
  • Phone: 617-524-2305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1030337
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: