Provider Demographics
NPI:1932124047
Name:ACEVEDO, ANGELICA (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:
Last Name:ACEVEDO
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 1:27 CONGRESS ST STE 205-19
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-5595
Mailing Address - Country:US
Mailing Address - Phone:617-312-8563
Mailing Address - Fax:978-208-7021
Practice Address - Street 1:27 CONGRESS ST STE 205-19
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-5595
Practice Address - Country:US
Practice Address - Phone:617-312-8563
Practice Address - Fax:978-208-7021
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22171363L00000X
MA1140521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000165502OtherMEDICARE IDENTIFICATION NUMBER
MA70010000P09434OtherBLUCE CROSS BLUE SHIELD HMO, PPO AND INDEMINITY