Provider Demographics
NPI:1457456360
Name:DECKER KIGNER, ROBERTA (LICSW)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:DECKER KIGNER
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 1:43 OLD COLONY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581
Mailing Address - Country:US
Mailing Address - Phone:508-836-3943
Mailing Address - Fax:508-872-0861
Practice Address - Street 1:45 LYMAN ST STE 19
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-2658
Practice Address - Country:US
Practice Address - Phone:508-330-4196
Practice Address - Fax:508-366-7270
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1049861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP03321Medicare ID - Type Unspecified