Provider Demographics
NPI:1689701351
Name:FOUGERE, DIANE (LICSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:FOUGERE
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 1:202 RUSSELL ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2265
Mailing Address - Country:US
Mailing Address - Phone:508-797-7128
Mailing Address - Fax:
Practice Address - Street 1:435 SHREWSBURY ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-1689
Practice Address - Country:US
Practice Address - Phone:508-753-5554
Practice Address - Fax:508-752-7245
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105459104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker