=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477033470
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOWARD JAY BARSOOK X SMW, LCISW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2018
-----------------------------------------------------
Last Update Date | 08/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 COMMONWEALTH CT APT 15
-----------------------------------------------------
City | BRIGHTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02135-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-232-3084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 DIMOCK ST
-----------------------------------------------------
City | ROXBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02119-1210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-989-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 1020629
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------