Provider Demographics
NPI:1851452692
Name:GERTEL, REVA L (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:REVA
Middle Name:L
Last Name:GERTEL
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 1:90 HOLLAND RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-5721
Mailing Address - Country:US
Mailing Address - Phone:617-277-3168
Mailing Address - Fax:508-370-0283
Practice Address - Street 1:90 HOLLAND RD
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-5721
Practice Address - Country:US
Practice Address - Phone:617-277-3168
Practice Address - Fax:508-370-0283
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10263481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07784OtherBLUE CROSSBLUE SHIELD
MAP07784OtherBLUE CROSSBLUE SHIELD