Basic Information
| Provider Information | |||||||||
| NPI: | 1184684060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SYLVIA | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 67 BRYANT ST | ||||||||
| Address2: | |||||||||
| City: | BERKLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027791504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088219340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 178 PINE STREET | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086780091 | ||||||||
| FaxNumber: | 5083249002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 3028159 | MA | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 3028159 | 01 | MA | LICENSE | OTHER |