Healthcare Provider Details

I. General information

NPI: 1699888479
Provider Name (Legal Business Name): JAMES S. DIREDA LICSW, PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 BURNCOAT ST
WORCESTER MA
01605-1331
US

IV. Provider business mailing address

3 LESLEY LN
STERLING MA
01564-2364
US

V. Phone/Fax

Practice location:
  • Phone: 508-361-4258
  • Fax:
Mailing address:
  • Phone: 508-361-4258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW1029269-1
License Number StateMA

VII. Legacy identifiers

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

# 1
IdentifierP08350
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS OF MA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: