Provider Demographics
NPI:1508914631
Name:DERONCK, JOHN JAMES (LICSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JAMES
Last Name:DERONCK
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 1:12 KERRIGAN PL
Mailing Address - Street 2:APT 2
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7626
Mailing Address - Country:US
Mailing Address - Phone:617-731-7864
Mailing Address - Fax:
Practice Address - Street 1:27 HOLLIS ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-8615
Practice Address - Country:US
Practice Address - Phone:508-872-3333
Practice Address - Fax:508-875-2600
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1138971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical