Provider Demographics
NPI:1982623872
Name:CONWAY, SALLY ALICE (LICSW)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ALICE
Last Name:CONWAY
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 1:608 FAIRWAY VLG
Mailing Address - Street 2:
Mailing Address - City:LEEDS
Mailing Address - State:MA
Mailing Address - Zip Code:01053-9746
Mailing Address - Country:US
Mailing Address - Phone:413-582-0230
Mailing Address - Fax:
Practice Address - Street 1:104 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3160
Practice Address - Country:US
Practice Address - Phone:413-587-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1075001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1852931Medicaid
MAPO6729Medicare ID - Type Unspecified