MEDICARE: MRS. RE BECCA LYNN KOSTERMAN 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	113002	MA

General Provider Information

NPI Number	:	1437186830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RE BECCA LYNN KOSTERMAN LICSW

Provider Business Mailing Address
First Line	:	124 FELLSWAY W
Second Line	:	UNIT #3
City	:	MEDFORD
State	:	MA
Zip	:	02155-2708
Country	:	US
Telephone Number	:	617-894-5910
Fax Number	:

Provider Business Practice Location Address
First Line	:	76 BEDFORD ST
Second Line	:	SUITE #19
City	:	LEXINGTON
State	:	MA
Zip	:	02420-4646
Country	:	US
Telephone Number	:	617-894-5910
Fax Number	:

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	07/08/2007

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