Provider Demographics
NPI:1003936162
Name:STREETER, SUSAN BOYD (LICSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:BOYD
Last Name:STREETER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:WACC 037
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-643-3590
Mailing Address - Fax:617-724-1800
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:WACC 037
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-643-3590
Practice Address - Fax:617-724-1800
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1029961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA102996OtherMASS SOCIAL WORK LICENSE