Provider Demographics
NPI:1306111273
Name:YOUNG, THERESA S (MA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:S
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:SUSAN
Other - Last Name:KELLIHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1010 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2600
Mailing Address - Country:US
Mailing Address - Phone:617-419-3408
Mailing Address - Fax:617-534-2611
Practice Address - Street 1:774 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2520
Practice Address - Country:US
Practice Address - Phone:617-534-7730
Practice Address - Fax:857-288-2200
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222706104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker