Provider Demographics
NPI:1679660856
Name:STEVENS, BROOKS (LICSW)
Entity Type:Individual
Prefix:
First Name:BROOKS
Middle Name:
Last Name:STEVENS
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 1:76 BEDFORD ST
Mailing Address - Street 2:SUITE 21
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420
Mailing Address - Country:US
Mailing Address - Phone:978-340-3349
Mailing Address - Fax:978-369-6877
Practice Address - Street 1:76 BEDFORD ST
Practice Address - Street 2:SUITE 21
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-4646
Practice Address - Country:US
Practice Address - Phone:978-340-3349
Practice Address - Fax:978-369-6877
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1025355104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP22991OtherMEDICARE PTAN
MA1859757Medicaid