Provider Demographics
NPI:1275088759
Name:DERRY, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:DERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MORNINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01505-1916
Mailing Address - Country:US
Mailing Address - Phone:508-615-0410
Mailing Address - Fax:
Practice Address - Street 1:81 PLANTATION ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-3069
Practice Address - Country:US
Practice Address - Phone:508-549-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor