Healthcare Provider Details

I. General information

NPI: 1114425675
Provider Name (Legal Business Name): JUDITH DIO WENTZELL MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UMASSMEMORIAL MEDICAL CENTER, 55 LAKE AVE NORTH DEPT OF CARE COORDINATION
WORCESTER MA
01655
US

IV. Provider business mailing address

78 S QUINSIGAMOND AVE UNIT 1
SHREWSBURY MA
01545-4268
US

V. Phone/Fax

Practice location:
  • Phone: 774-442-3879
  • Fax: 774-441-9705
Mailing address:
  • Phone: 774-442-3879
  • Fax: 774-441-9705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1015722
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: