Provider Demographics
NPI:1083787956
Name:DURKIN, MYRA VANCE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:VANCE
Last Name:DURKIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 MORRISON AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2017
Mailing Address - Country:US
Mailing Address - Phone:617-628-7155
Mailing Address - Fax:617-628-7155
Practice Address - Street 1:211 MORRISON AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2017
Practice Address - Country:US
Practice Address - Phone:617-628-7155
Practice Address - Fax:617-628-7155
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1067691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1859277Medicaid
MAP04303OtherBCBS
MA761457OtherTUFTS
MA161311000OtherMAGELLAN
MAP04303Medicare ID - Type Unspecified