Provider Demographics
NPI:1003954587
Name:CARPENTER, MARY THERESA (LSW, MA , MA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:THERESA
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:LSW, MA , MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 FAIRHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-3140
Mailing Address - Country:US
Mailing Address - Phone:508-735-9555
Mailing Address - Fax:
Practice Address - Street 1:250 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1726
Practice Address - Country:US
Practice Address - Phone:508-752-4665
Practice Address - Fax:508-752-0947
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA310405101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional