Basic Information
| Provider Information | |||||||||
| NPI: | 1023161841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASEY | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GORMAN | ||||||||
| OtherFirstName: | MAUREEN | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | B.A. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 585 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016051906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088543320 | ||||||||
| FaxNumber: | 5087535051 | ||||||||
| Practice Location | |||||||||
| Address1: | 76 SUMMER ST | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014205783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783432433 | ||||||||
| FaxNumber: | 9783430791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 2220002001 | 01 | MA | BCBS SUBSTANCE ABUSE | OTHER | M18684 | 01 | MA | MENTAL HEALTH | OTHER | 1308785 | 05 | MA | MEDICAID | 1306421 | 05 | MA | MEDICAID |