Provider Demographics
NPI:1841363504
Name:PERSE, RICHARD A (LICSW)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:PERSE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MAIN ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-1914
Mailing Address - Country:US
Mailing Address - Phone:508-393-7223
Mailing Address - Fax:508-393-7026
Practice Address - Street 1:112 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-1914
Practice Address - Country:US
Practice Address - Phone:508-393-7223
Practice Address - Fax:508-393-7026
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106697104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAR42321WMedicare UPIN
MAPO4248Medicare ID - Type Unspecified