=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518330984
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRISTINA VEGA GOVERMAN LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2015
-----------------------------------------------------
Last Update Date | 08/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 780 AMERICAN LEGION HWY
-----------------------------------------------------
City | ROSLINDALE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02131-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-294-0915
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 COOLIDGE AVE
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02062-5736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-287-4854
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 221079
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 120736
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------