Provider Demographics
NPI:1174888911
Name:PROVDA, RAQUEL MELYSSA (LICSW)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:MELYSSA
Last Name:PROVDA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CIRCLE AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01905-3050
Mailing Address - Country:US
Mailing Address - Phone:781-595-2413
Mailing Address - Fax:
Practice Address - Street 1:11 CIRCLE AVE
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01905-3050
Practice Address - Country:US
Practice Address - Phone:781-595-2413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW11208181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical