1366513525 NPI number — MS. JUDITH D. BRALOVE MSW, LICSW

Table of content: MS. JUDITH D. BRALOVE MSW, LICSW (NPI 1366513525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366513525 NPI number — MS. JUDITH D. BRALOVE MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRALOVE
Provider First Name:
JUDITH
Provider Middle Name:
D.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366513525
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
76 SUMMER ST
Provider Second Line Business Mailing Address:
SUITE #145
Provider Business Mailing Address City Name:
FITCHBURG
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01420-5783
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-342-8280
Provider Business Mailing Address Fax Number:
978-343-9408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
76 SUMMER ST
Provider Second Line Business Practice Location Address:
SUITE #145
Provider Business Practice Location Address City Name:
FITCHBURG
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01420-5783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-342-8280
Provider Business Practice Location Address Fax Number:
978-343-9408
Provider Enumeration Date:
11/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  104615 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P02825 . This is a "BLUE CROSS PROVIDER #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 104615 . This is a "PROF. LIC. NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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