Provider Demographics
NPI:1801928437
Name:MUSHACKE, LORRAINE S (LICSW)
Entity type:Individual
Prefix:MS
First Name:LORRAINE
Middle Name:S
Last Name:MUSHACKE
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 1:115 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03581-1627
Mailing Address - Country:US
Mailing Address - Phone:603-466-5059
Mailing Address - Fax:603-466-5059
Practice Address - Street 1:115 MAIN ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:NH
Practice Address - Zip Code:03581-1627
Practice Address - Country:US
Practice Address - Phone:603-466-5059
Practice Address - Fax:603-466-5059
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30423882Medicaid
NH30423882Medicaid