Provider Demographics
NPI:1649329921
Name:ILUSTRE, IRMA R (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:IRMA
Middle Name:R
Last Name:ILUSTRE
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ALFRED ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1915
Mailing Address - Country:US
Mailing Address - Phone:781-646-0500
Mailing Address - Fax:781-646-7130
Practice Address - Street 1:170 MAIN ST
Practice Address - Street 2:UNIT G-02
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-1765
Practice Address - Country:US
Practice Address - Phone:617-969-7600
Practice Address - Fax:617-969-7646
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1121721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical