Healthcare Provider Details

I. General information

NPI: 1265866628
Provider Name (Legal Business Name): MARY ROSE MOODIE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 PARTRIDGE ST
FRANKLIN MA
02038-1519
US

IV. Provider business mailing address

82 PARTRIDGE ST
FRANKLIN MA
02038-1519
US

V. Phone/Fax

Practice location:
  • Phone: 508-212-7549
  • Fax:
Mailing address:
  • Phone: 508-212-7549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: