Provider Demographics
NPI:1093409500
Name:DEJESUS, TATIANA (LCSW)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:DEJESUS
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 1:26 S STREET CT
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01905-2824
Mailing Address - Country:US
Mailing Address - Phone:781-439-7112
Mailing Address - Fax:
Practice Address - Street 1:199 ROSEWOOD DR STE 300
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-1388
Practice Address - Country:US
Practice Address - Phone:978-291-7066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA229235101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health