Healthcare Provider Details

I. General information

NPI: 1669528006
Provider Name (Legal Business Name): GREGORY STOODLEY LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 WARREN ST
BRIGHTON MA
02135-3601
US

IV. Provider business mailing address

89 LONDONDERRY RD
FRAMINGHAM MA
01701-4377
US

V. Phone/Fax

Practice location:
  • Phone: 617-254-0964
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number112168
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: