Provider Demographics
NPI:1124304720
Name:CARVALLO, SANTIAGO ALFONSO (MSW)
Entity type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:ALFONSO
Last Name:CARVALLO
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 TOURO AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-7124
Mailing Address - Country:US
Mailing Address - Phone:617-331-7674
Mailing Address - Fax:
Practice Address - Street 1:301 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150-2807
Practice Address - Country:US
Practice Address - Phone:617-889-4860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS771425901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical