Healthcare Provider Details

I. General information

NPI: 1922467380
Provider Name (Legal Business Name): ANDREA CONSTANTINO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LINCOLN ST
WORCESTER MA
01605-2407
US

IV. Provider business mailing address

4925 WASHINGTON ST #402
WEST ROXBURY MA
02132-2100
US

V. Phone/Fax

Practice location:
  • Phone: 508-753-6263
  • Fax:
Mailing address:
  • Phone: 617-997-6519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number116188
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: