Basic Information
| Provider Information | |||||||||
| NPI: | 1407956782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAVALLERANO | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | JOBETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 LINCOLN ST | ||||||||
| Address2: | #202 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021112402 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1025 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEST BARNSTABLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026681125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083624141 | ||||||||
| FaxNumber: | 5083624141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1026172 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 135085 | 01 | MA | VALUE OPTIONS | OTHER | 407788 | 01 | MA | MAGELLAN | OTHER | 1851837 | 05 | MA | MEDICAID | P07964 | 01 | MA | BLUECROSSBLUESHIELD | OTHER |