=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972686178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANICE DIANNE PALKEN TERVO LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 52 CEDAR ST PSYCHIATRY AND FAMILY COUNSELING
-----------------------------------------------------
City | WOCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-752-5191
-----------------------------------------------------
Fax | 508-792-1514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 GEORGE ST
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01460-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-952-2578
-----------------------------------------------------
Fax | 978-486-0354
-----------------------------------------------------
=====================================================
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 | 1019446
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------