Provider Demographics
NPI:1790842052
Name:STACEY J RUTHERFORD, LICSW P.C.
Entity Type:Organization
Organization Name:STACEY J RUTHERFORD, LICSW P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:JENEE
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW, MSW
Authorized Official - Phone:508-438-0110
Mailing Address - Street 1:198 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2200
Mailing Address - Country:US
Mailing Address - Phone:508-438-0110
Mailing Address - Fax:
Practice Address - Street 1:198 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2200
Practice Address - Country:US
Practice Address - Phone:508-438-0110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1106481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP22582Medicare ID - Type UnspecifiedLICSW