Provider Demographics
NPI:1659855971
Name:BUNNELL, CHRISTINE COLLINS (LICSW)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:COLLINS
Last Name:BUNNELL
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 1:587 WELD ST
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-1302
Mailing Address - Country:US
Mailing Address - Phone:201-410-0534
Mailing Address - Fax:
Practice Address - Street 1:309 WAVERLEY OAKS RD
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-8443
Practice Address - Country:US
Practice Address - Phone:210-410-0534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1174171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAU46287055OtherCIGNA HEALTH INSURANCE