MEDICARE: JONATHAN W REUSSER 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	10367	MA

General Provider Information

NPI Number	:	1639164627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN W REUSSER LICSW

Provider Business Mailing Address
First Line	:	76 BEDFORD ST
Second Line	:	SUITE 25
City	:	LEXINGTON
State	:	MA
Zip	:	02420-4646
Country	:	US
Telephone Number	:	781-861-1879
Fax Number	:	781-861-1879

Provider Business Practice Location Address
First Line	:	76 BEDFORD ST
Second Line	:	SUITE 25
City	:	LEXINGTON
State	:	MA
Zip	:	02420-4646
Country	:	US
Telephone Number	:	781-861-1879
Fax Number	:	781-861-1879

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

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	07/08/2007

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