Healthcare Provider Details

I. General information

NPI: 1245652965
Provider Name (Legal Business Name): TISIA CIESLUK LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 WILLIAM ST
WORCESTER MA
01609-2336
US

IV. Provider business mailing address

P.O. BOX 34
WESTBORO MA
01581
US

V. Phone/Fax

Practice location:
  • Phone: 508-791-5540
  • Fax: 508-799-6325
Mailing address:
  • Phone: 508-870-0647
  • Fax: 508-799-6325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number116724
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: