Healthcare Provider Details

I. General information

NPI: 1922691914
Provider Name (Legal Business Name): HAROLD JACKSON AYALA RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 UNION ST STE 3
WORCESTER MA
01608-1141
US

IV. Provider business mailing address

342 SOUTHWICK RD APT 94
WESTFIELD MA
01085-4793
US

V. Phone/Fax

Practice location:
  • Phone: 413-326-6641
  • Fax:
Mailing address:
  • Phone: 413-326-6641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW229300
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: