Provider Demographics
NPI:1962870212
Name:MCCLUSKEY, JOANN
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:MCCLUSKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52-B WAYSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089
Mailing Address - Country:US
Mailing Address - Phone:413-427-9980
Mailing Address - Fax:
Practice Address - Street 1:52B WAYSIDE AVE
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-1316
Practice Address - Country:US
Practice Address - Phone:413-427-9980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMASSMedicaid