Provider Demographics
NPI:1497140651
Name:MEDEIROS, MARY-JO
Entity Type:Individual
Prefix:MRS
First Name:MARY-JO
Middle Name:
Last Name:MEDEIROS
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 1:35 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-3469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 SUMMER ST
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-3469
Practice Address - Country:US
Practice Address - Phone:508-828-1308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3025362101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health