Provider Demographics
NPI:1720255565
Name:CAVICCHIO, CRISTA MARY (LCSW)
Entity type:Individual
Prefix:MISS
First Name:CRISTA
Middle Name:MARY
Last Name:CAVICCHIO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 NEWBURY ST # 2
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2442
Mailing Address - Country:US
Mailing Address - Phone:617-823-8668
Mailing Address - Fax:
Practice Address - Street 1:366 SOMERVILLE AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-2919
Practice Address - Country:US
Practice Address - Phone:617-628-8815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2136691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA213669OtherLCSW