Provider Demographics
NPI:1366022873
Name:WOOD, AUDREY ROGOVIN (LCSW)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:ROGOVIN
Last Name:WOOD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 BOYLSTON ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 ELM ST
Practice Address - Street 2:
Practice Address - City:MAYNARD
Practice Address - State:MA
Practice Address - Zip Code:01754-2628
Practice Address - Country:US
Practice Address - Phone:978-844-2717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0002261251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000226125OtherSOCIAL WORK LICENSE