Provider Demographics
NPI:1437432002
Name:SMITH, TERESA KATHERINE
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:KATHERINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 GALLIVAN BLVD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-4528
Mailing Address - Country:US
Mailing Address - Phone:617-322-9731
Mailing Address - Fax:
Practice Address - Street 1:63 GALLIVAN BLVD
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-4528
Practice Address - Country:US
Practice Address - Phone:617-322-9731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker