Provider Demographics
NPI:1639424724
Name:CLOUGHERTY, COLLEEN E (LCSW)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:E
Last Name:CLOUGHERTY
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 1:43 DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-5103
Mailing Address - Country:US
Mailing Address - Phone:781-306-4821
Mailing Address - Fax:
Practice Address - Street 1:43 DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5103
Practice Address - Country:US
Practice Address - Phone:781-306-4821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
MA221971104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist