Provider Demographics
NPI:1992895767
Name:STASON, SUSAN B (LICSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:B
Last Name:STASON
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 1:1565 MAIN ST
Mailing Address - Street 2:BLDG 2 SUITE 200
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876
Mailing Address - Country:US
Mailing Address - Phone:978-851-5515
Mailing Address - Fax:978-851-5561
Practice Address - Street 1:1565 MAIN ST
Practice Address - Street 2:BLDG 2 SUITE 200
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876
Practice Address - Country:US
Practice Address - Phone:978-851-5515
Practice Address - Fax:978-851-5561
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105310104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA105310OtherSOC WRK LICENSE
MA105310OtherSOC WRK LICENSE
P03696Medicare UPIN