Provider Demographics
NPI:1417240706
Name:SPIVACK, ALLEN MARK (LICSW)
Entity Type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:MARK
Last Name:SPIVACK
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 1:55 DIMOCK ST
Mailing Address - Street 2:ROOM 309
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1029
Mailing Address - Country:US
Mailing Address - Phone:617-442-8800
Mailing Address - Fax:617-427-1126
Practice Address - Street 1:55 DIMOCK ST
Practice Address - Street 2:ROOM 309
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1029
Practice Address - Country:US
Practice Address - Phone:617-442-8800
Practice Address - Fax:617-427-1126
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10298021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical