Provider Demographics
NPI:1518075027
Name:NATHAN, AUDREY RUBIN (LICSW)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:RUBIN
Last Name:NATHAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:NAN
Other - Last Name:RUBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:372 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-6202
Mailing Address - Country:US
Mailing Address - Phone:781-239-3550
Mailing Address - Fax:781-239-3272
Practice Address - Street 1:372 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-6202
Practice Address - Country:US
Practice Address - Phone:781-239-3550
Practice Address - Fax:781-239-3272
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1063011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP04864OtherBLUE CROSS BLUE SHIELD MA
MA715605OtherTUFTS HEALTH PLAN
MAP04864OtherBLUE CROSS BLUE SHIELD MA