Provider Demographics
NPI:1710461124
Name:LIST, AVIVA L (LICSW)
Entity Type:Individual
Prefix:
First Name:AVIVA
Middle Name:L
Last Name:LIST
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 1:9 EMERSON RD
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-3401
Mailing Address - Country:US
Mailing Address - Phone:646-645-4680
Mailing Address - Fax:
Practice Address - Street 1:312 MILLBURY AVE
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:MA
Practice Address - Zip Code:01527-3622
Practice Address - Country:US
Practice Address - Phone:646-645-4680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1203511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical