Provider Demographics
NPI:1326161944
Name:CAVALLACCI, GABRIELLE (LICSW)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:CAVALLACCI
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LONGWOOD AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5239
Mailing Address - Country:US
Mailing Address - Phone:617-731-5857
Mailing Address - Fax:
Practice Address - Street 1:1415 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4816
Practice Address - Country:US
Practice Address - Phone:617-566-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10242951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1854348Medicaid