Provider Demographics
NPI:1053555342
Name:LOGUIDICE, MICHAEL (LICSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LOGUIDICE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 COMMONWEALTH AVE
Mailing Address - Street 2:SUITE 906
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2349
Mailing Address - Country:US
Mailing Address - Phone:857-305-3177
Mailing Address - Fax:
Practice Address - Street 1:29 COMMONWEALTH AVE
Practice Address - Street 2:SUITE 906
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-2349
Practice Address - Country:US
Practice Address - Phone:857-305-3177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1184091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7348161OtherUHC