Provider Demographics
NPI:1558493411
Name:BONAFACCIA, CLAIRE E (MSW)
Entity type:Individual
Prefix:
First Name:CLAIRE
Middle Name:E
Last Name:BONAFACCIA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 LAKE SHORE RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-6358
Mailing Address - Country:US
Mailing Address - Phone:781-437-1323
Mailing Address - Fax:
Practice Address - Street 1:2020 CENTRE ST
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-3316
Practice Address - Country:US
Practice Address - Phone:781-437-1323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1312677Medicaid
MAM18708OtherBLUE CROSS
MA685661OtherTUFTS
MA1312677Medicaid