MEDICARE: SOUTHEAST ADOLESCENT AND ADULT COUNSELING

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	105297	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1005325	OTHER	FALLON COMMUNITY HEALTH PLAN
2	109603	OTHER	BLUE CROSS/ BLUE SHIELD HMO
3	2078990	OTHER	CIGNA
4	P04466	OTHER	BLUE CROSS/BLUE SHIELD
5	1005325	OTHER	NEIGHBORHOOD HEALTH PLAN
6	007377	OTHER	HARVARD PILGRIM HEALTHCARE
7	453450	OTHER	TUFTS

General Provider Information

NPI Number	:	1780830448
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST ADOLESCENT AND ADULT COUNSELING

Provider Business Mailing Address
First Line	:	455 W CENTER ST
Second Line	:	SUITE 3
City	:	WEST BRIDGEWATER
State	:	MA
Zip	:	02379-1637
Country	:	US
Telephone Number	:	508-954-4431
Fax Number	:

Provider Business Practice Location Address
First Line	:	455 W CENTER ST
Second Line	:	SUITE 3
City	:	WEST BRIDGEWATER
State	:	MA
Zip	:	02379-1637
Country	:	US
Telephone Number	:	508-954-4431
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	MARYLOU SHEARING
Credential	:	LICSW
Telephone Number	:	508-954-4431

Provider Enumeration Date	:	08/13/2008
Last Update Date	:	08/13/2008

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Directions to “SOUTHEAST ADOLESCENT AND ADULT COUNSELING ” Practice Location

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