Provider Demographics
NPI:1073865077
Name:CARON, MARK P (LICSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:CARON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WATERHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:BOURNE
Mailing Address - State:MA
Mailing Address - Zip Code:02532-3897
Mailing Address - Country:US
Mailing Address - Phone:508-759-7279
Mailing Address - Fax:774-302-4978
Practice Address - Street 1:16 WATERHOUSE RD
Practice Address - Street 2:
Practice Address - City:BOURNE
Practice Address - State:MA
Practice Address - Zip Code:02532-3897
Practice Address - Country:US
Practice Address - Phone:508-759-7279
Practice Address - Fax:774-302-4978
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 1041C0700X
MA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker