Provider Demographics
NPI:1073652228
Name:FEDERICO, CAROLLYN (LICSW)
Entity Type:Individual
Prefix:
First Name:CAROLLYN
Middle Name:
Last Name:FEDERICO
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:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:NH
Mailing Address - Zip Code:03825-0383
Mailing Address - Country:US
Mailing Address - Phone:603-664-6888
Mailing Address - Fax:603-664-6888
Practice Address - Street 1:20 MADBURY ROAD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NH
Practice Address - Zip Code:03824
Practice Address - Country:US
Practice Address - Phone:603-664-6888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30421697Medicaid