Provider Demographics
NPI:1841704194
Name:KLICKSTEIN, STACY BETH (LICSW)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:BETH
Last Name:KLICKSTEIN
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 1:1153 CENTRE ST STE 5H
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3446
Mailing Address - Country:US
Mailing Address - Phone:617-983-7025
Mailing Address - Fax:
Practice Address - Street 1:1153 CENTRE ST STE 5H
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-983-7025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-24
Last Update Date:2017-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1131281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical