Healthcare Provider Details

I. General information

NPI: 1720168719
Provider Name (Legal Business Name): ROBERTA ANN NAGLE LCSW LADAC1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 LINCOLN STREET
WORCESTER MA
01605
US

IV. Provider business mailing address

585 LINCOLN STREET
WORCESTER MA
01605
US

V. Phone/Fax

Practice location:
  • Phone: 508-854-3320
  • Fax: 508-753-5051
Mailing address:
  • Phone: 508-854-3320
  • Fax: 508-753-5051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number204233
License Number StateMA

VII. Legacy identifiers

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

# 1
Identifier1308785
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS MH M18684
# 2
Identifier1306421
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 3
Identifier2220002001
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS SUBSTANCE ABUSE
# 4
Identifier1308785
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerMEDICID MENTAL HEALTH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: