Provider Demographics
NPI:1003062688
Name:HIGGINBOTTOM, LARRY (MSW / LCSW)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:HIGGINBOTTOM
Suffix:
Gender:M
Credentials:MSW / LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 DUDLEY ST
Mailing Address - Street 2:SUITE 107 LL
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2561
Mailing Address - Country:US
Mailing Address - Phone:617-442-2002
Mailing Address - Fax:617-442-4002
Practice Address - Street 1:184 DUDLEY ST
Practice Address - Street 2:SUITE 107 LL
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-2561
Practice Address - Country:US
Practice Address - Phone:617-442-2002
Practice Address - Fax:617-442-4002
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20301311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical