Provider Demographics
NPI:1912194036
Name:KOCH-SULTAN, RHEA M (LICSW)
Entity Type:Individual
Prefix:
First Name:RHEA
Middle Name:M
Last Name:KOCH-SULTAN
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 1:55 CAMBRIDGE STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01803-4612
Mailing Address - Country:US
Mailing Address - Phone:781-221-3180
Mailing Address - Fax:781-221-3183
Practice Address - Street 1:55 CAMBRIDGE STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-4612
Practice Address - Country:US
Practice Address - Phone:781-221-3180
Practice Address - Fax:781-221-3183
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212181104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA002539201Medicare UPIN