=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184649840
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM P GOOLEY LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 01/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13 ARLINGTON ST
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01501-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-798-6699
-----------------------------------------------------
Fax | 508-798-7011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 696 MAIN ST
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01545-3012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-845-7463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1024170
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------