Healthcare Provider Details

I. General information

NPI: 1154812956
Provider Name (Legal Business Name): JUDITH SAMUELS FONSH MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 LONG HILL RD
LEVERETT MA
01054-9749
US

IV. Provider business mailing address

45 LONG HILL RD
LEVERETT MA
01054-9749
US

V. Phone/Fax

Practice location:
  • Phone: 413-548-9053
  • Fax:
Mailing address:
  • Phone: 413-548-9053
  • Fax: 413-773-9009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101707
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: