Provider Demographics
NPI:1871809111
Name:MAURICE, MYRTISE (LICSW)
Entity type:Individual
Prefix:
First Name:MYRTISE
Middle Name:
Last Name:MAURICE
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 1:1525 BLUE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02126-1702
Mailing Address - Country:US
Mailing Address - Phone:617-356-8242
Mailing Address - Fax:
Practice Address - Street 1:181 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3505
Practice Address - Country:US
Practice Address - Phone:617-230-5210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
S400300482Medicare PIN