Provider Demographics
NPI:1851450878
Name:HALLISEY, BONNIE JOYCE (LICSW)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:JOYCE
Last Name:HALLISEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-1327
Mailing Address - Country:US
Mailing Address - Phone:617-825-5000
Mailing Address - Fax:617-288-5991
Practice Address - Street 1:1500 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-1327
Practice Address - Country:US
Practice Address - Phone:617-825-5000
Practice Address - Fax:617-288-5991
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103203104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303511Medicaid
MA1303511Medicaid