Provider Demographics
NPI:1760199459
Name:MUSGRAVE, THERESA L (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:MUSGRAVE
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 1:413 CHANDLER ST
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-2826
Mailing Address - Country:US
Mailing Address - Phone:978-767-6418
Mailing Address - Fax:
Practice Address - Street 1:500 W CUMMINGS PARK STE 4100
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6515
Practice Address - Country:US
Practice Address - Phone:978-744-1099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226354104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA226354OtherLICENSED CERTIFIED SOCIAL WORKER