Provider Demographics
NPI:1265592257
Name:VANRHEENEN, CONNIE (LICSW)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:
Last Name:VANRHEENEN
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 1:158 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4876
Mailing Address - Country:US
Mailing Address - Phone:617-417-1805
Mailing Address - Fax:617-547-3735
Practice Address - Street 1:158 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4876
Practice Address - Country:US
Practice Address - Phone:617-417-1805
Practice Address - Fax:617-547-3735
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1108451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1857886Medicaid
MAP07872OtherBLUE CROSS BLUE SHIELD
MA1857886Medicaid