Provider Demographics
NPI:1013952753
Name:STUBBLEFIELD-TAVE, JANICE (MA, LICSW)
Entity type:Individual
Prefix:MS
First Name:JANICE
Middle Name:
Last Name:STUBBLEFIELD-TAVE
Suffix:
Gender:F
Credentials:MA, LICSW
Other - Prefix:MS
Other - First Name:JANICE
Other - Middle Name:
Other - Last Name:TAVE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:27 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-1001
Mailing Address - Country:US
Mailing Address - Phone:617-596-1309
Mailing Address - Fax:
Practice Address - Street 1:173 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4005
Practice Address - Country:US
Practice Address - Phone:617-596-1309
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1078691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAST P23196Medicare ID - Type Unspecified