Provider Demographics
NPI:1104965458
Name:BRACKEN, HILARY (LICSW, BOD)
Entity type:Individual
Prefix:
First Name:HILARY
Middle Name:
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:LICSW, BOD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4861
Mailing Address - Country:US
Mailing Address - Phone:617-864-6840
Mailing Address - Fax:617-864-6840
Practice Address - Street 1:18 WILLARD ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4861
Practice Address - Country:US
Practice Address - Phone:617-864-6840
Practice Address - Fax:617-864-6840
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1063671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO4090OtherBLUE CROSS BLUE SHIELD