Provider Demographics
NPI:1760626998
Name:CULLINANE, PETER SEAN (LICSW)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:SEAN
Last Name:CULLINANE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PHILLIPS LN
Mailing Address - Street 2:
Mailing Address - City:NEWTONVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02460-2219
Mailing Address - Country:US
Mailing Address - Phone:617-694-5170
Mailing Address - Fax:
Practice Address - Street 1:11 PHILLIPS LN
Practice Address - Street 2:
Practice Address - City:NEWTONVILLE
Practice Address - State:MA
Practice Address - Zip Code:02460-2219
Practice Address - Country:US
Practice Address - Phone:617-694-5170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MA113667171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical