Healthcare Provider Details

I. General information

NPI: 1487165072
Provider Name (Legal Business Name): HEATHER B MANDEVILLE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER B FLYNN LCSW

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 10/07/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 GOLD STAR BLVD
WORCESTER MA
01606-2738
US

IV. Provider business mailing address

135 GOLD STAR BLVD
WORCESTER MA
01606-2738
US

V. Phone/Fax

Practice location:
  • Phone: 508-459-6400
  • Fax: 508-849-5618
Mailing address:
  • Phone: 508-459-6400
  • Fax: 508-849-5618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLICSW124058
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW224417
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: