Provider Demographics
NPI:1982711768
Name:MIGNONE, PAULA (LICSW)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:MIGNONE
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 1:84 SANBORN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-3837
Mailing Address - Country:US
Mailing Address - Phone:617-325-6833
Mailing Address - Fax:
Practice Address - Street 1:332 WASHINGTON ST
Practice Address - Street 2:SUITE 380
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-6219
Practice Address - Country:US
Practice Address - Phone:617-325-6833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10154321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
15052OtherUS BEHAVIORAL HEALTH
PO4626OtherBC/BS
49140OtherUNITED HEALTHCARE
199255OtherHEALTHSOURCE
49140OtherUNITED BEHAVIORAL HEALTH
6280055OtherEVERCARE
908166OtherAFFORDABLE MEDICAL NETWOR
49140OtherUNITED BEHAVIORAL HEALTH