Provider Demographics
NPI:1801370275
Name:NOVACK, MICHAEL JONATHAN (LICSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JONATHAN
Last Name:NOVACK
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 1:15 BROOK ST STE 5
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-2058
Mailing Address - Country:US
Mailing Address - Phone:508-785-8300
Mailing Address - Fax:508-785-8020
Practice Address - Street 1:15 BROOK ST STE 5
Practice Address - Street 2:
Practice Address - City:MEDFIELD
Practice Address - State:MA
Practice Address - Zip Code:02052-2058
Practice Address - Country:US
Practice Address - Phone:508-785-8300
Practice Address - Fax:508-785-8020
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110115104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker