Provider Demographics
NPI:1740761121
Name:HERMANTO, JULIATY (LICSW)
Entity Type:Individual
Prefix:
First Name:JULIATY
Middle Name:
Last Name:HERMANTO
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 1:99 LORING DRIVE
Mailing Address - Street 2:ATTN: MENTAL HEALTH
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02143
Mailing Address - Country:US
Mailing Address - Phone:626-298-0997
Mailing Address - Fax:
Practice Address - Street 1:99 LORING DRIVE
Practice Address - Street 2:ATTN: MENTAL HEALTH
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02143
Practice Address - Country:US
Practice Address - Phone:626-298-0997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1211571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical