Provider Demographics
NPI:1841397825
Name:REISMAN, DEBORAH MAX (LICSW)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:MAX
Last Name:REISMAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:
Other - Last Name:REISMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:75 BEETHOVEN AVE
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-1732
Mailing Address - Country:US
Mailing Address - Phone:617-332-3980
Mailing Address - Fax:
Practice Address - Street 1:151 MYSTIC AVE
Practice Address - Street 2:SUITE SIX
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4632
Practice Address - Country:US
Practice Address - Phone:781-396-1199
Practice Address - Fax:781-396-1439
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1066451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP04193OtherBCBS
MAP04193OtherBCBS