Provider Demographics
NPI:1699168476
Name:QUERUSIO, JEFFERY STEPHEN
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:STEPHEN
Last Name:QUERUSIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 MUNROE STREET
Mailing Address - Street 2:APT 1
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143
Mailing Address - Country:US
Mailing Address - Phone:857-204-6110
Mailing Address - Fax:
Practice Address - Street 1:8 MUNROE ST
Practice Address - Street 2:APT 1
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-2009
Practice Address - Country:US
Practice Address - Phone:857-204-6110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS69194867101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA40550OtherELIOT COMMUNITY HUMAN SERVICES
MAS69194867OtherMASSACHUSERRS DRIVER'S LICENSE