1134390669 NPI number — MARILYN A RAY 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 1134390669 NPI number — MARILYN A RAY LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAY
Provider First Name:
MARILYN
Provider Middle Name:
A
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:
OHEARN
Provider Other First Name:
MARILYN
Provider Other Middle Name:
A
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:
1134390669
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
585 LINCOLN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01605-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-831-0045
Provider Business Mailing Address Fax Number:
508-735-5051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
76 SUMMER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FITCHBURG
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01420-5783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-343-2433
Provider Business Practice Location Address Fax Number:
978-343-0791
Provider Enumeration Date:
03/12/2008

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: 101YA0400X , with the licence number:  1032768 , 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: 1306421 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1308785 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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