Provider Demographics
NPI:1811025497
Name:HIGGINBOTTOM, VERONICA LAKE (MSW)
Entity Type:Individual
Prefix:MS
First Name:VERONICA
Middle Name:LAKE
Last Name:HIGGINBOTTOM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 ALPINE ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3403
Mailing Address - Country:US
Mailing Address - Phone:617-983-5800
Mailing Address - Fax:617-983-5840
Practice Address - Street 1:157 GREEN ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2667
Practice Address - Country:US
Practice Address - Phone:617-983-5800
Practice Address - Fax:617-983-5840
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2041571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical