Provider Demographics
NPI:1790839207
Name:TETRAULT, SIMONE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:SIMONE
Middle Name:
Last Name:TETRAULT
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 1:448 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746-1440
Mailing Address - Country:US
Mailing Address - Phone:617-610-0137
Mailing Address - Fax:
Practice Address - Street 1:448 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:HOLLISTON
Practice Address - State:MA
Practice Address - Zip Code:01746-1440
Practice Address - Country:US
Practice Address - Phone:617-610-0137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1115451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MATEP23732Medicare ID - Type Unspecified