Provider Demographics
NPI:1083901904
Name:HENNIGAN, MARILYN ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:ANN
Last Name:HENNIGAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:ANN
Other - Last Name:HENNIGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:275 BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-1675
Mailing Address - Country:US
Mailing Address - Phone:508-791-3261
Mailing Address - Fax:508-795-1338
Practice Address - Street 1:275 BELMONT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-1675
Practice Address - Country:US
Practice Address - Phone:508-791-3261
Practice Address - Fax:508-795-1338
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10230391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical