1841397825 NPI number — DEBORAH MAX REISMAN LICSW

Table of content: DEBORAH MAX REISMAN LICSW (NPI 1841397825)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841397825 NPI number — DEBORAH MAX REISMAN LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REISMAN
Provider First Name:
DEBORAH
Provider Middle Name:
MAX
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REISMAN
Provider Other First Name:
DEBORAH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1841397825
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 BEETHOVEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WABAN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02468-1732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-332-3980
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 MYSTIC AVE
Provider Second Line Business Practice Location Address:
SUITE SIX
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155-4632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-396-1199
Provider Business Practice Location Address Fax Number:
781-396-1439
Provider Enumeration Date:
09/20/2006

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:  106645 , 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: P04193 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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