Healthcare Provider Details

I. General information

NPI: 1164781720
Provider Name (Legal Business Name): JEREMY SANTACROCE, RN/NP, LICSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 BOSTON POST RD UNIT 4C
SUDBURY MA
01776-3022
US

IV. Provider business mailing address

323 BOSTON POST RD UNIT 4C
SUDBURY MA
01776-3022
US

V. Phone/Fax

Practice location:
  • Phone: 978-443-6960
  • Fax: 978-443-6502
Mailing address:
  • Phone: 978-443-6960
  • Fax: 978-443-6502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number114229
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN2264377
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JEREMY SANTACROCE
Title or Position: OWNER
Credential: RN/NP, LICSW
Phone: 978-443-6960