Provider Demographics
NPI:1689703548
Name:SIMON-ULYSSE, PHANIDE (LICSW)
Entity Type:Individual
Prefix:
First Name:PHANIDE
Middle Name:
Last Name:SIMON-ULYSSE
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 1:90 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-1843
Mailing Address - Country:US
Mailing Address - Phone:617-875-6299
Mailing Address - Fax:
Practice Address - Street 1:90 CENTER ST
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1843
Practice Address - Country:US
Practice Address - Phone:617-875-6299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1156531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical