Provider Demographics
NPI:1740785500
Name:O'NEILL, TEGAN (LICSW)
Entity Type:Individual
Prefix:
First Name:TEGAN
Middle Name:
Last Name:O'NEILL
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 1:1949 COMMONWEALTH AVE APT 24
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-5913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 DIMOCK ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1208
Practice Address - Country:US
Practice Address - Phone:617-442-8800
Practice Address - Fax:617-541-8472
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1244551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UKB983336842OtherBLUE CROSS BLUE SHIELD