Healthcare Provider Details

I. General information

NPI: 1730656331
Provider Name (Legal Business Name): TAMMY MARIE SHELDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 QUEEN ST
WORCESTER MA
01610-2411
US

IV. Provider business mailing address

12 QUEEN ST
WORCESTER MA
01610-2411
US

V. Phone/Fax

Practice location:
  • Phone: 508-860-1032
  • Fax:
Mailing address:
  • Phone: 508-860-1032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number125033
License Number StateMA

VII. Legacy identifiers

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

# 1
Identifier110189259A
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: