Healthcare Provider Details

I. General information

NPI: 1528483666
Provider Name (Legal Business Name): LOUISA RACHEL KHETTAB LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 BANK ROW ST FL 3
GREENFIELD MA
01301-3599
US

IV. Provider business mailing address

25 BANK ROW ST FL 3
GREENFIELD MA
01301-3599
US

V. Phone/Fax

Practice location:
  • Phone: 413-367-4938
  • Fax:
Mailing address:
  • Phone: 413-367-4938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number124051
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: