Provider Demographics
NPI:1114029006
Name:SMITH, ADELAIDE S (LICSW)
Entity Type:Individual
Prefix:
First Name:ADELAIDE
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FITCHBURG ST APT C220
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-2127
Mailing Address - Country:US
Mailing Address - Phone:617-764-0056
Mailing Address - Fax:425-799-8790
Practice Address - Street 1:2464 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-1646
Practice Address - Country:US
Practice Address - Phone:617-930-6902
Practice Address - Fax:425-799-8790
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW016401041C0700X
MA1032941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP01256OtherBLUESHIELD AND BLUECROSS
MAP01256OtherBLUESHIELD AND BLUECROSS