Healthcare Provider Details

I. General information

NPI: 1437637519
Provider Name (Legal Business Name): TRACI LYNN CUCINOTTA LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 HIGHLAND AVE APT 2
WINTHROP MA
02152-1545
US

IV. Provider business mailing address

158 HIGHLAND AVE APT 2
WINTHROP MA
02152-1545
US

V. Phone/Fax

Practice location:
  • Phone: 978-808-1941
  • Fax:
Mailing address:
  • Phone: 978-808-1941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11884
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: