Provider Demographics
NPI:1154812956
Name:FONSH, JUDITH SAMUELS (MSW)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:SAMUELS
Last Name:FONSH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:LEVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:01054-9749
Mailing Address - Country:US
Mailing Address - Phone:413-548-9053
Mailing Address - Fax:413-773-9009
Practice Address - Street 1:45 LONG HILL RD
Practice Address - Street 2:
Practice Address - City:LEVERETT
Practice Address - State:MA
Practice Address - Zip Code:01054-9749
Practice Address - Country:US
Practice Address - Phone:413-548-9053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1017071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical