Basic Information
Provider Information | |||||||||
NPI: | 1790857837 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MUNROE | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, MS, CS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 142 APSLEY ST | ||||||||
Address2: |   | ||||||||
City: | HUDSON | ||||||||
State: | MA | ||||||||
PostalCode: | 017491615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088601011 | ||||||||
FaxNumber: | 5088601068 | ||||||||
Practice Location | |||||||||
Address1: | 72 JAQUES AVE | ||||||||
Address2: | COMMUNITY HEALTH LINK | ||||||||
City: | WORCESTER | ||||||||
State: | MA | ||||||||
PostalCode: | 016102476 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088601011 | ||||||||
FaxNumber: | 5088601069 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 116525 | MA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 116525 | 01 | MA | RN LICENSE | OTHER |