Provider Demographics
NPI:1164551768
Name:KUZNICK, ALISSA SUSAN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:ALISSA
Middle Name:SUSAN
Last Name:KUZNICK
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 1:144 FULLER ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-2803
Mailing Address - Country:US
Mailing Address - Phone:617-795-0248
Mailing Address - Fax:617-795-0263
Practice Address - Street 1:92 HIGH ST
Practice Address - Street 2:DH7
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3850
Practice Address - Country:US
Practice Address - Phone:781-393-8889
Practice Address - Fax:781-396-3948
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1109781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP023091Medicare ID - Type Unspecified