Provider Demographics
NPI:1891837811
Name:WEISS, MARTHA DEBORAH (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:DEBORAH
Last Name:WEISS
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 1:85 HYDE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-2334
Mailing Address - Country:US
Mailing Address - Phone:617-964-7406
Mailing Address - Fax:
Practice Address - Street 1:10 LANGLEY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-1972
Practice Address - Country:US
Practice Address - Phone:617-969-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1042721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWEP03099OtherBLUE CROSS BLUE SHIELD
MAWEP22761Medicare ID - Type Unspecified