Provider Demographics
NPI:1932256989
Name:LAFARGE, PHYLLIS N (LICSW MAC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:N
Last Name:LAFARGE
Suffix:
Gender:F
Credentials:LICSW MAC
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSW
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:HOUSATONIC
Mailing Address - State:MA
Mailing Address - Zip Code:01236-0663
Mailing Address - Country:US
Mailing Address - Phone:413-298-5207
Mailing Address - Fax:
Practice Address - Street 1:60 COTTAGE ST
Practice Address - Street 2:MAIN ST HUMAN RESOURCES BRIEN CENTER
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1302
Practice Address - Country:US
Practice Address - Phone:413-528-9155
Practice Address - Fax:413-528-8187
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1072511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA31731OtherHEALTH NEW ENGLAND
MAP20801Medicare ID - Type UnspecifiedMEDICARE