Provider Demographics
NPI:1285118257
Name:DEITMER, CHANDI LOUISE (LICSW)
Entity type:Individual
Prefix:
First Name:CHANDI
Middle Name:LOUISE
Last Name:DEITMER
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 1:19 CHANDLER ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1911
Mailing Address - Country:US
Mailing Address - Phone:201-281-2350
Mailing Address - Fax:
Practice Address - Street 1:77 4TH AVE STE 5
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-7567
Practice Address - Country:US
Practice Address - Phone:781-795-7252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1200041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical