MEDICARE: KATHLEEN MARY BAMBRICK LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1022668	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P06631	OTHER	MA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1154341253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN MARY BAMBRICK LICSW

Provider Business Mailing Address
First Line	:	500 VICTORY RD
Second Line	:
City	:	QUINCY
State	:	MA
Zip	:	02171-3139
Country	:	US
Telephone Number	:	617-774-1002
Fax Number	:	617-328-5021

Provider Business Practice Location Address
First Line	:	859 WILLARD ST
Second Line	:	SUITE 430
City	:	QUINCY
State	:	MA
Zip	:	02169-7482
Country	:	US
Telephone Number	:	617-774-1002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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