Provider Demographics
NPI:1669452462
Name:NESSANBAUM, BONNIE (LICSW)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:NESSANBAUM
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 1:38 PICKNEY ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145
Mailing Address - Country:US
Mailing Address - Phone:617-628-3555
Mailing Address - Fax:
Practice Address - Street 1:1565 MAIN ST
Practice Address - Street 2:BLD.2 ROOM 206
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-2085
Practice Address - Country:US
Practice Address - Phone:617-628-3555
Practice Address - Fax:617-288-3910
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10166201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical