Healthcare Provider Details

I. General information

NPI: 1528429818
Provider Name (Legal Business Name): MICHELLE MARIE FAGNANO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 09/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 LINCOLN STREET
WORCESTER MA
01605
US

IV. Provider business mailing address

424 JOHN MAHAR HWY UNIT 209
BRAINTREE MA
02184-6576
US

V. Phone/Fax

Practice location:
  • Phone: 617-512-2198
  • Fax:
Mailing address:
  • Phone: 617-587-1593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106332
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: