Provider Demographics
NPI:1447501119
Name:CARDOSO, SERENA J
Entity type:Individual
Prefix:
First Name:SERENA
Middle Name:J
Last Name:CARDOSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:617-419-3408
Mailing Address - Fax:617-534-2611
Practice Address - Street 1:112 SOUTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2711
Practice Address - Country:US
Practice Address - Phone:617-534-7098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MA10634101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator