1497761266 NPI number — MARYLYN DUNLAP COLBURN LICSW

Table of content: MARYLYN DUNLAP COLBURN LICSW (NPI 1497761266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497761266 NPI number — MARYLYN DUNLAP COLBURN LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLBURN
Provider First Name:
MARYLYN
Provider Middle Name:
DUNLAP
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:
LOWREY
Provider Other First Name:
MARYLYN
Provider Other Middle Name:
DUNLAP
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497761266
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 OLD DERBY ST
Provider Second Line Business Mailing Address:
SUITE 451
Provider Business Mailing Address City Name:
HINGHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02043-4005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-688-5165
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1132 WESTFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST SPRINGFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01089-3878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-592-1980
Provider Business Practice Location Address Fax Number:
413-439-0096
Provider Enumeration Date:
07/31/2006

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:  106297 , 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: P00418015 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".