MEDICARE: RAQUEL MELYSSA PROVDA 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	LICSW1120818	MA

General Provider Information

NPI Number	:	1174888911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAQUEL MELYSSA PROVDA LICSW

Provider Business Mailing Address
First Line	:	11 CIRCLE AVE
Second Line	:
City	:	LYNN
State	:	MA
Zip	:	01905-3050
Country	:	US
Telephone Number	:	781-595-2413
Fax Number	:

Provider Business Practice Location Address
First Line	:	41 MALL RD
Second Line	:
City	:	BURLINGTON
State	:	MA
Zip	:	01805-0001
Country	:	US
Telephone Number	:	781-744-8000
Fax Number	:

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

Provider Enumeration Date	:	07/09/2012
Last Update Date	:	12/02/2025

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