Provider Demographics
NPI:1689647398
Name:ERTEL, GERALDINE B (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:GERALDINE
Middle Name:B
Last Name:ERTEL
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 1:22 MILL ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-4784
Mailing Address - Country:US
Mailing Address - Phone:781-643-9266
Mailing Address - Fax:781-646-2950
Practice Address - Street 1:22 MILL ST
Practice Address - Street 2:SUITE 302
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4784
Practice Address - Country:US
Practice Address - Phone:781-643-9266
Practice Address - Fax:781-646-2950
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1003341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAERP22374Medicare ID - Type Unspecified