Provider Demographics
NPI:1376690594
Name:TANNENBAUM, JODY (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JODY
Middle Name:
Last Name:TANNENBAUM
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 1:94 PLEASANT ST STE 22
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-6527
Mailing Address - Country:US
Mailing Address - Phone:781-316-1771
Mailing Address - Fax:
Practice Address - Street 1:94 PLEASANT ST STE 22
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-6527
Practice Address - Country:US
Practice Address - Phone:781-316-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10167371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP2772569OtherOXFORD
MA7238206OtherAETNA
MAP05126OtherBLUE CROSS
MA1894609OtherMBHP
MA1894609OtherMBHP