MEDICARE: MR. TIMOTHY WAYNE STANTON LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	104372-1	MA

General Provider Information

NPI Number	:	1336275692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIMOTHY WAYNE STANTON LICSW

Provider Business Mailing Address
First Line	:	117 PARK AVE
Second Line	:	SUITE 200
City	:	WEST SPRINGFIELD
State	:	MA
Zip	:	01089-3327
Country	:	US
Telephone Number	:	413-209-3124
Fax Number	:	413-209-3127

Provider Business Practice Location Address
First Line	:	117 PARK AVE
Second Line	:	SUITE 200
City	:	WEST SPRINGFIELD
State	:	MA
Zip	:	01089-3327
Country	:	US
Telephone Number	:	413-209-3124
Fax Number	:	413-209-3127

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	07/08/2007

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