Provider Demographics
NPI:1104220961
Name:MANISCALCO, BENJAMIN (LICSW)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MANISCALCO
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S BEDFORD ST STE 208
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01803-5145
Mailing Address - Country:US
Mailing Address - Phone:781-309-7207
Mailing Address - Fax:
Practice Address - Street 1:111 S BEDFORD ST STE 208
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-5145
Practice Address - Country:US
Practice Address - Phone:781-309-7207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA1228791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program