Provider Demographics
NPI:1780738146
Name:FALLSTROM, CHRISTINE (LICSW)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:
Last Name:FALLSTROM
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 1:78 RICH ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-1263
Mailing Address - Country:US
Mailing Address - Phone:508-756-1626
Mailing Address - Fax:508-756-2080
Practice Address - Street 1:37 FRUIT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2184
Practice Address - Country:US
Practice Address - Phone:508-753-7434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10219651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO6559Medicare UPIN
MA1033610Medicare UPIN
MAP23831Medicare ID - Type Unspecified