Provider Demographics
NPI:1710254685
Name:PENNACCHIA, DAVID PAUL (MSW, LICSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:PAUL
Last Name:PENNACCHIA
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3675
Mailing Address - Country:US
Mailing Address - Phone:781-485-6306
Mailing Address - Fax:
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3675
Practice Address - Country:US
Practice Address - Phone:781-485-6306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1144591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical