Healthcare Provider Details

I. General information

NPI: 1871604090
Provider Name (Legal Business Name): JEANNE VUMBACA LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 JAQUES AVE
WORCESTER MA
01610-2476
US

IV. Provider business mailing address

17 W ELM ST
HOPKINTON MA
01748-1603
US

V. Phone/Fax

Practice location:
  • Phone: 508-860-1154
  • Fax:
Mailing address:
  • Phone: 508-435-5912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1023495-1
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: