Provider Demographics
NPI:1710013420
Name:CRESTA, RICHARD J (LICSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:J
Last Name:CRESTA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 ORLEANS ST
Mailing Address - Street 2:402
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-2105
Mailing Address - Country:US
Mailing Address - Phone:617-763-6749
Mailing Address - Fax:
Practice Address - Street 1:150 ORLEANS ST
Practice Address - Street 2:402
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-2105
Practice Address - Country:US
Practice Address - Phone:617-763-6749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10296431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1890093Medicaid