Basic Information
| Provider Information | |||||||||
| NPI: | 1215153952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MODENA | ||||||||
| FirstName: | ANNE | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 GROVE ST | ||||||||
| Address2: | # 110 | ||||||||
| City: | WEST ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021324549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173254917 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1261 FURNACE BROOK PKWY STE 31 | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021694787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174794545 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 07/17/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 201527 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.