Healthcare Provider Details

I. General information

NPI: 1164516175
Provider Name (Legal Business Name): MARY THERESA JOHNSON M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 HIGHLAND STREET
WORCESTER MA
01602
US

IV. Provider business mailing address

338 HIGHLAND STREET
WORCESTER MA
01602
US

V. Phone/Fax

Practice location:
  • Phone: 508-752-5880
  • Fax: 508-831-9967
Mailing address:
  • Phone: 508-752-5880
  • Fax: 508-831-9967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1003
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: