Provider Demographics
NPI:1326123506
Name:SIMONEAU, GARY RAYMOND (LICSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:RAYMOND
Last Name:SIMONEAU
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 1:117 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2631
Mailing Address - Country:US
Mailing Address - Phone:617-629-4632
Mailing Address - Fax:
Practice Address - Street 1:599 NORTH AVE
Practice Address - Street 2:DOOR 8
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-1648
Practice Address - Country:US
Practice Address - Phone:781-224-9884
Practice Address - Fax:781-224-9632
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1027144101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP20332Medicare ID - Type UnspecifiedMEDICARE B PROVIDER NUMBE