Healthcare Provider Details

I. General information

NPI: 1104877133
Provider Name (Legal Business Name): SHERRI GRANDE DIREDA LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 BURNCOAT ST
WORCESTER MA
01605-1331
US

IV. Provider business mailing address

3 LESLEY LN
STERLING MA
01564-2364
US

V. Phone/Fax

Practice location:
  • Phone: 508-453-1266
  • Fax:
Mailing address:
  • Phone: 978-422-9090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1019512
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: