Provider Demographics
NPI:1215343231
Name:SUSHCHYK, MALCOLM ROSE (LICSW 00012367)
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:ROSE
Last Name:SUSHCHYK
Suffix:
Gender:M
Credentials:LICSW 00012367
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 PRINCETON RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:MA
Mailing Address - Zip Code:01564-2708
Mailing Address - Country:US
Mailing Address - Phone:650-516-6672
Mailing Address - Fax:
Practice Address - Street 1:163 PRINCETON RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:MA
Practice Address - Zip Code:01564-2708
Practice Address - Country:US
Practice Address - Phone:650-516-6672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW75117101Y00000X
MA000123679101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA99467OtherBOARD OF BEHAVIORAL SCIENCES