=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871594911
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAWRENCE R AUSTIN LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2005
-----------------------------------------------------
Last Update Date | 03/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 BAY STATE CT
-----------------------------------------------------
City | BREWSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02631-2120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-255-8375
-----------------------------------------------------
Fax | 508-240-5448
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 CEDAR LN
-----------------------------------------------------
City | BREWSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02631-2144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-240-7964
-----------------------------------------------------
Fax | 508-240-5448
-----------------------------------------------------
=====================================================
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 | 1031291
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------