1023096930 NPI number — MELLISSA J REARICK LICSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023096930 NPI number — MELLISSA J REARICK LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REARICK
Provider First Name:
MELLISSA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023096930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
99 LINCOLN ST
Provider Second Line Business Mailing Address:
CANCER CARE CENTER
Provider Business Mailing Address City Name:
FRAMINGHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01702-6327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-383-8529
Provider Business Mailing Address Fax Number:
508-383-8584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
99 LINCOLN ST
Provider Second Line Business Practice Location Address:
CANCER CARE CENTER
Provider Business Practice Location Address City Name:
FRAMINGHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01702-6327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-383-8529
Provider Business Practice Location Address Fax Number:
508-383-8584
Provider Enumeration Date:
01/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  113171 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 92684 . This is a "FALLON COMMUNITY HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "TRICARE CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P23784 . This is a "MEDICARE B" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "ONE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".




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