Provider Demographics
NPI:1891822169
Name:DECTER, PHILIP R (MSW, LICSW)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:R
Last Name:DECTER
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 BOYLSTON ST # 3
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4424
Mailing Address - Country:US
Mailing Address - Phone:617-413-0447
Mailing Address - Fax:617-924-5111
Practice Address - Street 1:51 KONDAZIAN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2830
Practice Address - Country:US
Practice Address - Phone:617-413-0447
Practice Address - Fax:617-924-5111
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10310201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1895338Medicaid
MA1895338Medicaid