Healthcare Provider Details

I. General information

NPI: 1306060397
Provider Name (Legal Business Name): SUSAN DAWN WORTHEN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 09/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

386 STANLEY ST
FALL RIVER MA
02720-6009
US

IV. Provider business mailing address

386 STANLEY ST
FALL RIVER MA
02720-6009
US

V. Phone/Fax

Practice location:
  • Phone: 508-679-5222
  • Fax: 508-676-5671
Mailing address:
  • Phone: 508-679-5222
  • Fax: 508-676-5671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW02004
License Number StateRI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierISW02004
Identifier TypeOTHER
Identifier StateRI
Identifier IssuerLICSW LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: