Healthcare Provider Details

I. General information

NPI: 1326394750
Provider Name (Legal Business Name): FAY LUCILLE CHAMPOUX L.I.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2012
Last Update Date: 08/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 BEACON ST., BOSTON INSTITUTE FOR PSYCHOTHERAPY SUITE 120
BROOKLINE MA
02446
US

IV. Provider business mailing address

21 TREEHOUSE CIR APARTMENT 3
EASTHAMPTON MA
01027-2175
US

V. Phone/Fax

Practice location:
  • Phone: 617-566-2200
  • Fax:
Mailing address:
  • Phone: 413-459-1479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111365
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: