Healthcare Provider Details

I. General information

NPI: 1790842052
Provider Name (Legal Business Name): STACEY J RUTHERFORD, LICSW P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 RUSSELL ST
WORCESTER MA
01609-2200
US

IV. Provider business mailing address

198 RUSSELL ST
WORCESTER MA
01609-2200
US

V. Phone/Fax

Practice location:
  • Phone: 508-438-0110
  • Fax:
Mailing address:
  • Phone: 508-438-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110648
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: STACEY JENEE RUTHERFORD
Title or Position: PRESIDENT
Credential: LICSW, MSW
Phone: 508-438-0110