Provider Demographics
NPI:1487102224
Name:WIGHT, TIMOTHY (LICSW)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:WIGHT
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-5801
Mailing Address - Country:US
Mailing Address - Phone:617-771-6582
Mailing Address - Fax:
Practice Address - Street 1:360 ROUTE 101 STE 13B
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-5033
Practice Address - Country:US
Practice Address - Phone:603-488-1773
Practice Address - Fax:844-907-2936
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2022-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3136239Medicaid