Provider Demographics
NPI:1164921516
Name:PACKARD, NICHOLAS (LICSW)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:PACKARD
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 1:429 WASHINGTON ST APT 6
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-6130
Mailing Address - Country:US
Mailing Address - Phone:857-919-4700
Mailing Address - Fax:
Practice Address - Street 1:69 UNION ST STE 1
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-2252
Practice Address - Country:US
Practice Address - Phone:617-778-4942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224356104100000X
390200000X
MA0001232751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program