Provider Demographics
NPI:1295014819
Name:KAUFMAN, GREGORY MARK (LICSW)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:MARK
Last Name:KAUFMAN
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 1:78 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1916
Mailing Address - Country:US
Mailing Address - Phone:617-623-3278
Mailing Address - Fax:
Practice Address - Street 1:78 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-1916
Practice Address - Country:US
Practice Address - Phone:617-623-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-13
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA116040101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)