Provider Demographics
NPI:1053418608
Name:PEDULLA, TOM (LICSW)
Entity type:Individual
Prefix:MR
First Name:TOM
Middle Name:
Last Name:PEDULLA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:PEDULLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:390 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-6799
Mailing Address - Country:US
Mailing Address - Phone:617-803-0951
Mailing Address - Fax:781-643-0039
Practice Address - Street 1:390 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474-6799
Practice Address - Country:US
Practice Address - Phone:617-803-0951
Practice Address - Fax:781-643-0039
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1115971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA$$$$$$$$$OtherSSN