=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205840246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS V. GROTE LICSW CADAC-II
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 11/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 FRANKLIN ST
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01301-2912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-774-2704
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 LINCOLN ST
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01301-2016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-773-8155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 0893AL
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1030868
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------