Healthcare Provider Details

I. General information

NPI: 1205946530
Provider Name (Legal Business Name): CAMILLE G ST. ONGE II L.I.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAMILLE G SUPKA L.I.C.S.W

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 WENDELL RD
MILLERS FALLS MA
01349-1315
US

IV. Provider business mailing address

316 WENDELL RD
MILLERS FALLS MA
01349-1315
US

V. Phone/Fax

Practice location:
  • Phone: 413-768-8013
  • Fax:
Mailing address:
  • Phone: 413-768-8013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1023144
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: