Provider Demographics
NPI:1588982920
Name:IDE, ANN MARIE ELIZABETH (LICSW)
Entity type:Individual
Prefix:
First Name:ANN MARIE
Middle Name:ELIZABETH
Last Name:IDE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ANN MARIE
Other - Middle Name:ELIZABETH
Other - Last Name:GUILLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:72 ADDINGTON RD # 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-4520
Mailing Address - Country:US
Mailing Address - Phone:617-513-7103
Mailing Address - Fax:
Practice Address - Street 1:41 GARRISON RD
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-4445
Practice Address - Country:US
Practice Address - Phone:617-277-8107
Practice Address - Fax:617-734-6385
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1155591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical