Provider Demographics
NPI:1659418564
Name:DAVID-FORS, JUNE ALICE (LICSW)
Entity Type:Individual
Prefix:
First Name:JUNE
Middle Name:ALICE
Last Name:DAVID-FORS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2343 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:MA
Mailing Address - Zip Code:01523-2421
Mailing Address - Country:US
Mailing Address - Phone:978-537-2579
Mailing Address - Fax:
Practice Address - Street 1:71 ELM ST
Practice Address - Street 2:SUITE 204B
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2353
Practice Address - Country:US
Practice Address - Phone:508-755-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10188041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1307665Medicaid
MA270660000OtherMAGELLAN HEALTH SERVICES
MA1307665Medicaid
MAPO6982Medicare UPIN