Provider Demographics
NPI:1528168135
Name:RUTHERFORD, STACEY JENEE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:JENEE
Last Name:RUTHERFORD
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 1:198 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2200
Mailing Address - Country:US
Mailing Address - Phone:508-438-0110
Mailing Address - Fax:508-753-5100
Practice Address - Street 1:435 SHREWSBURY ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-1638
Practice Address - Country:US
Practice Address - Phone:508-577-2017
Practice Address - Fax:508-752-7245
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1106481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP22582Medicare ID - Type Unspecified