Provider Demographics
NPI:1740779495
Name:CIVILETTO, CHRISTINE L (PHD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:L
Last Name:CIVILETTO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 FORSYTH BUILDING
Mailing Address - Street 2:360 HUNTINGTON AVENUE
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-373-4139
Mailing Address - Fax:
Practice Address - Street 1:135 FORSYTH BUILDING
Practice Address - Street 2:360 HUNTINGTON AVENUE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-373-4139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8884103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling