Provider Demographics
NPI:1063815348
Name:BOETTCHER, TERRI (LICSW)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:BOETTCHER
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 1:72 JACQUES STREET
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610
Mailing Address - Country:US
Mailing Address - Phone:508-373-7893
Mailing Address - Fax:508-860-1210
Practice Address - Street 1:72 JACQUES STREET
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610
Practice Address - Country:US
Practice Address - Phone:508-373-7893
Practice Address - Fax:508-860-1210
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX344091041C0700X
171M00000X
MA1208441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator