Provider Demographics
NPI:1699964973
Name:ALTIDOR, TANIA (LICSW)
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:ALTIDOR
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:TANIA
Other - Middle Name:
Other - Last Name:PIERRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2908
Practice Address - Country:US
Practice Address - Phone:617-414-5245
Practice Address - Fax:617-414-5520
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1169501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110137189AMedicaid