Provider Demographics
NPI:1144387564
Name:CLENDANIEL, DEBORAH OLDS (LICSW)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:OLDS
Last Name:CLENDANIEL
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 1:55 ALCOTT RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2642
Mailing Address - Country:US
Mailing Address - Phone:781-863-1124
Mailing Address - Fax:
Practice Address - Street 1:1666 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-5317
Practice Address - Country:US
Practice Address - Phone:781-863-1124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1108201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07992OtherBLUE CROSS BLUE SHIELD
MA2348843000OtherMAGELLAN BEHAVORIAL HEALT
MAP07992OtherBLUE CROSS BLUE SHIELD