MEDICARE: CHRISTINE DESTEFANO CHOATE 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	1029580	MA

General Provider Information

NPI Number	:	1609341601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE DESTEFANO CHOATE LICSW

Provider Business Mailing Address
First Line	:	45 WALL ST
Second Line	:
City	:	WELLESLEY
State	:	MA
Zip	:	02481-4819
Country	:	US
Telephone Number	:	781-856-9699
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 WALNUT ST
Second Line	:
City	:	NEWTON
State	:	MA
Zip	:	02460-1314
Country	:	US
Telephone Number	:	617-559-6041
Fax Number	:

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

Provider Enumeration Date	:	10/05/2018
Last Update Date	:	10/05/2018

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