Healthcare Provider Details

I. General information

NPI: 1003954587
Provider Name (Legal Business Name): MARY THERESA CARPENTER LSW, MA , MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 COMMERCIAL ST
WORCESTER MA
01608-1726
US

IV. Provider business mailing address

148 FAIRHAVEN RD
WORCESTER MA
01606-3140
US

V. Phone/Fax

Practice location:
  • Phone: 508-752-4665
  • Fax: 508-752-0947
Mailing address:
  • Phone: 508-735-9555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number310405
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: