Provider Demographics
NPI:1144337239
Name:BROE, BONNIE JEAN (LICSW)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:JEAN
Last Name:BROE
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 1:3 OTIS PL APT 9
Mailing Address - Street 2:
Mailing Address - City:SCITUATE
Mailing Address - State:MA
Mailing Address - Zip Code:02066-1338
Mailing Address - Country:US
Mailing Address - Phone:781-544-3995
Mailing Address - Fax:781-544-3996
Practice Address - Street 1:80 WASHINGTON ST STE F31
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1741
Practice Address - Country:US
Practice Address - Phone:781-878-2822
Practice Address - Fax:781-544-3996
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1059991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO3942Medicare ID - Type Unspecified