Provider Demographics
NPI:1164877973
Name:CORREIA, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:CORREIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 CLARKSON ST
Mailing Address - Street 2:1
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2529
Mailing Address - Country:US
Mailing Address - Phone:617-590-9231
Mailing Address - Fax:
Practice Address - Street 1:64 CLARKSON ST
Practice Address - Street 2:1
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-2529
Practice Address - Country:US
Practice Address - Phone:617-590-9231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst