Provider Demographics
NPI:1104987155
Name:KOHLER, STACEY R (LICSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:KOHLER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 WALNUT ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-7500
Mailing Address - Country:US
Mailing Address - Phone:508-572-9225
Mailing Address - Fax:
Practice Address - Street 1:223 WALNUT ST
Practice Address - Street 2:SUITE 1
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-7500
Practice Address - Country:US
Practice Address - Phone:508-562-9225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2016-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1120221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000078501Medicare PIN
1104987155Medicare NSC
0000785Medicare PIN