=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194746206
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAWRENCE J CIVALE LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 W SQUANTUM ST SUITE 21
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02171-2122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-947-3261
-----------------------------------------------------
Fax | 617-451-0803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 HANSON ST
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02118-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-947-3261
-----------------------------------------------------
Fax | 617-451-0803
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW 110606-1
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------