1740795004 NPI number — FAITH WOOD BREISBLATT MSW, LICSW

Table of content: FAITH WOOD BREISBLATT MSW, LICSW (NPI 1740795004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740795004 NPI number — FAITH WOOD BREISBLATT MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREISBLATT
Provider First Name:
FAITH
Provider Middle Name:
WOOD
Provider Name Prefix Text:
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:
1740795004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 TILESTON ST APT 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02113-1965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-312-0703
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1470 BEACON ST APT A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLINE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02446-2613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-487-4909
Provider Business Practice Location Address Fax Number:
617-487-4909
Provider Enumeration Date:
12/08/2017

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:  120673 , 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)





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