Provider Demographics
NPI:1356496723
Name:MYERS, MARILYN MCINTIRE (LICSW)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:MCINTIRE
Last Name:MYERS
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 1:825 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-1734
Mailing Address - Country:US
Mailing Address - Phone:508-822-6650
Mailing Address - Fax:508-822-6509
Practice Address - Street 1:825 BROADWAY
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-1734
Practice Address - Country:US
Practice Address - Phone:508-822-6650
Practice Address - Fax:508-822-6509
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10246211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA10P20116Medicare ID - Type Unspecified