Provider Demographics
NPI:1144347055
Name:GREGOIRE, CARRIE LYN (LICSW 111657)
Entity type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:LYN
Last Name:GREGOIRE
Suffix:
Gender:F
Credentials:LICSW 111657
Other - Prefix:MISS
Other - First Name:CARRIE
Other - Middle Name:LYN
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:70 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-2778
Mailing Address - Country:US
Mailing Address - Phone:508-821-7777
Mailing Address - Fax:
Practice Address - Street 1:70 MAIN ST
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-2778
Practice Address - Country:US
Practice Address - Phone:508-821-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1116571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1309161Medicaid