Provider Demographics
NPI:1386792661
Name:HIRSCH, TERA GRETCHEN (LICSW, PHD)
Entity type:Individual
Prefix:
First Name:TERA
Middle Name:GRETCHEN
Last Name:HIRSCH
Suffix:
Gender:F
Credentials:LICSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 CLYDE ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02460-2208
Mailing Address - Country:US
Mailing Address - Phone:617-413-5969
Mailing Address - Fax:
Practice Address - Street 1:233 HARVARD ST STE 305
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5017
Practice Address - Country:US
Practice Address - Phone:617-413-5969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111271101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAHIP23836Medicare ID - Type UnspecifiedSOCIAL WORKER
MAPO8579Medicare UPIN