Healthcare Provider Details

I. General information

NPI: 1659418564
Provider Name (Legal Business Name): JUNE ALICE DAVID-FORS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 ELM ST SUITE 204B
WORCESTER MA
01609-2353
US

IV. Provider business mailing address

2343 MAIN ST
LANCASTER MA
01523-2421
US

V. Phone/Fax

Practice location:
  • Phone: 508-755-4320
  • Fax:
Mailing address:
  • Phone: 978-537-2579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1018804
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1307665
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
Identifier270660000
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerMAGELLAN HEALTH SERVICES

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: