Provider Demographics
NPI:1982185229
Name:HARRISON, RICHARD IV (LICSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:HARRISON
Suffix:IV
Gender:M
Credentials:LICSW
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:COMPTON
Other - Last Name:HARRISON
Other - Suffix:IV
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:35 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4562
Mailing Address - Country:US
Mailing Address - Phone:617-949-0859
Mailing Address - Fax:
Practice Address - Street 1:33 BEDFORD ST STE 11
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-4403
Practice Address - Country:US
Practice Address - Phone:617-949-0859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1194421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical