Basic Information
| Provider Information | |||||||||
| NPI: | 1215190186 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILOVANOVIC | ||||||||
| FirstName: | MIODRAG | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 146 CLIFTON ST. | ||||||||
| Address2: | UNIT 10 | ||||||||
| City: | MALDEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021482579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172302556 | ||||||||
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| Practice Location | |||||||||
| Address1: | 675 MAIN ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818932003 | ||||||||
| FaxNumber: | 7816470183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 09/04/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.