Provider Demographics
NPI:1245372671
Name:WATSON PETERS, CAROLYN RUTH (LICENSED INDEPENDENT)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:RUTH
Last Name:WATSON PETERS
Suffix:
Gender:F
Credentials:LICENSED INDEPENDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 HEATHER DRIVE
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01701
Mailing Address - Country:US
Mailing Address - Phone:508-879-0395
Mailing Address - Fax:508-879-0395
Practice Address - Street 1:8 HEATHER DRIVE
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701
Practice Address - Country:US
Practice Address - Phone:508-879-0395
Practice Address - Fax:508-879-0395
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1016290MALICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWAP22249Medicare ID - Type Unspecified