Healthcare Provider Details

I. General information

NPI: 1588130868
Provider Name (Legal Business Name): KACY LYNN MIDURA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FATHER DEVALLES BLVD STE 303
FALL RIVER MA
02723-1511
US

IV. Provider business mailing address

1 FATHER DEVALLES BLVD STE 303
FALL RIVER MA
02723-1511
US

V. Phone/Fax

Practice location:
  • Phone: 401-523-5352
  • Fax:
Mailing address:
  • Phone: 508-523-5352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW2130598
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: