Provider Demographics
NPI:1225189657
Name:DALY, MARYELLEN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARYELLEN
Middle Name:
Last Name:DALY
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 1:165 QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2988
Mailing Address - Country:US
Mailing Address - Phone:508-897-2082
Mailing Address - Fax:
Practice Address - Street 1:209 QUINCY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2926
Practice Address - Country:US
Practice Address - Phone:508-942-2143
Practice Address - Fax:508-897-2075
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1069451041C0700X
RIISW002231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1305565Medicaid
MA166343000OtherMAGELLAN
MABRY10275Medicare ID - Type UnspecifiedMEDICARE B
MA166343000OtherMAGELLAN