Provider Demographics
NPI:1558377234
Name:LONDON, PHYLLIS G (LICSW)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:G
Last Name:LONDON
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 1:11 COLGATE RD
Mailing Address - Street 2:Y
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-7405
Mailing Address - Country:US
Mailing Address - Phone:781-235-2179
Mailing Address - Fax:781-431-0081
Practice Address - Street 1:25 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-1715
Practice Address - Country:US
Practice Address - Phone:617-277-2399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1019370101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP05622Medicare ID - Type Unspecified