Provider Demographics
NPI:1114538543
Name:WILLNER, MAYBELLINE
Entity Type:Individual
Prefix:
First Name:MAYBELLINE
Middle Name:
Last Name:WILLNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 GIFFORD ST UNIT 14B
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02540-3090
Mailing Address - Country:US
Mailing Address - Phone:508-524-4477
Mailing Address - Fax:
Practice Address - Street 1:543 NORTH ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-2782
Practice Address - Country:US
Practice Address - Phone:508-996-3154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA101YM0800XMedicaid