Healthcare Provider Details

I. General information

NPI: 1528432317
Provider Name (Legal Business Name): PETER DEZSO LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PETER ZAWROTNIAK LICSW

II. Dates (important events)

Enumeration Date: 11/17/2015
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-856-6580
  • Fax: 508-856-5990
Mailing address:
  • Phone: 800-885-2225
  • Fax: 508-334-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number120783
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: