=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689276594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS MICHAEL LORELLO MSW, LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2020
-----------------------------------------------------
Last Update Date | 11/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 152 SYLVAN ST
-----------------------------------------------------
City | DANVERS
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01923-3558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-222-3121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 POPLAR ST
-----------------------------------------------------
City | IPSWICH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01938-2336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-471-8240
-----------------------------------------------------
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 | 116404
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------