Provider Demographics
NPI:1013387455
Name:DESSERTINE, REBECCA L (LICSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:DESSERTINE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:DESSERTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 MOUNT VERNON ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-6147
Mailing Address - Country:US
Mailing Address - Phone:323-702-2340
Mailing Address - Fax:
Practice Address - Street 1:1696 MASSACHUSETTS AVE FL 2
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1803
Practice Address - Country:US
Practice Address - Phone:978-252-3442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MA1227781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA122778OtherDIVISION OF PROFESSIONAL LICENSURE