Healthcare Provider Details

I. General information

NPI: 1528180908
Provider Name (Legal Business Name): SUSAN ELLEN MOORE-BUTLER M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

877 CHARLTON ST
SOUTHBRIDGE MA
01550-1311
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9771
  • Fax: 508-765-3147
Mailing address:
  • Phone: 508-764-9701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: