Provider Demographics
NPI:1215410758
Name:STILWELL, MARYGINA
Entity Type:Individual
Prefix:
First Name:MARYGINA
Middle Name:
Last Name:STILWELL
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:PO BOX 255
Mailing Address - Street 2:
Mailing Address - City:GREEN HARBOR
Mailing Address - State:MA
Mailing Address - Zip Code:02041-0255
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 WARREN AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-6105
Practice Address - Country:US
Practice Address - Phone:617-635-9976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105443104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker