Healthcare Provider Details

I. General information

NPI: 1215282322
Provider Name (Legal Business Name): MARY TASHJIAN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY GOGERTY

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 JAQUES AVE
WORCESTER MA
01610-2476
US

IV. Provider business mailing address

72 JAQUES AVE
WORCESTER MA
01610-2476
US

V. Phone/Fax

Practice location:
  • Phone: 508-860-1154
  • Fax:
Mailing address:
  • Phone: 508-860-1135
  • Fax: 800-518-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number224540
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: