Provider Demographics
NPI:1043393374
Name:SLADE, CAROL (LICSW)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:SLADE
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 1:169 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-5356
Mailing Address - Country:US
Mailing Address - Phone:781-894-8440
Mailing Address - Fax:781-894-1202
Practice Address - Street 1:169 ELM ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-5356
Practice Address - Country:US
Practice Address - Phone:781-894-8440
Practice Address - Fax:781-894-1202
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1010161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303287Medicaid
1004745OtherNHP
MAM18633OtherBCBS
703136OtherTUFTS
MA1303287OtherMBHP
MAP10329OtherBCBS
NP01332OtherBOSTON MED
MAP10091Medicare ID - Type Unspecified
MA1303287Medicaid