Provider Demographics
NPI:1316000375
Name:SOSA, JUAN CARLOS (LICSW)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:CARLOS
Last Name:SOSA
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 1:11 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2588
Mailing Address - Country:US
Mailing Address - Phone:617-983-9698
Mailing Address - Fax:617-524-7610
Practice Address - Street 1:11 GREEN ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2588
Practice Address - Country:US
Practice Address - Phone:617-983-9698
Practice Address - Fax:617-524-7610
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10207731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1890581Medicaid
MA1890581Medicaid