Provider Demographics
NPI:1720581788
Name:CLARK-SJOGREN, TERESE KEATING
Entity Type:Individual
Prefix:
First Name:TERESE
Middle Name:KEATING
Last Name:CLARK-SJOGREN
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 1:25 UNION ST STE 3
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1141
Mailing Address - Country:US
Mailing Address - Phone:508-317-2323
Mailing Address - Fax:
Practice Address - Street 1:25 UNION ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1141
Practice Address - Country:US
Practice Address - Phone:508-317-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMHC10000199101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health