Healthcare Provider Details

I. General information

NPI: 1801834874
Provider Name (Legal Business Name): NATHAN DITTMER L.I.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GROVE ST
WORCESTER MA
01605-1271
US

IV. Provider business mailing address

7 MARSHALL ST APT. 5
CLINTON MA
01510-1542
US

V. Phone/Fax

Practice location:
  • Phone: 508-755-4485
  • Fax:
Mailing address:
  • Phone: 978-365-3808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110585
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: