Provider Demographics
NPI:1326581554
Name:THACH, SRAYLUCKYNA
Entity Type:Individual
Prefix:
First Name:SRAYLUCKYNA
Middle Name:
Last Name:THACH
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 1:35 ROXBURY ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2107
Mailing Address - Country:US
Mailing Address - Phone:508-769-3561
Mailing Address - Fax:
Practice Address - Street 1:35 ROXBURY ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2107
Practice Address - Country:US
Practice Address - Phone:508-769-3561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-20
Last Update Date:2016-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN23108921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical