Individual
JEANNE MARY INTERNICOLA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
210 OLD COLONY AVE, SOUTH BOSTON, MA 02127-2413
(617) 268-5000
Mailing address
675 E 4TH ST, SOUTH BOSTON, MA 02127-3063
(617) 268-5000
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
1915
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
043220123
—
MA
Enumeration date
02/05/2018
Last updated
02/05/2018
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