Provider Demographics
NPI:1497761266
Name:COLBURN, MARYLYN DUNLAP (LICSW)
Entity Type:Individual
Prefix:
First Name:MARYLYN
Middle Name:DUNLAP
Last Name:COLBURN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MARYLYN
Other - Middle Name:DUNLAP
Other - Last Name:LOWREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:160 OLD DERBY ST
Mailing Address - Street 2:SUITE 451
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-4005
Mailing Address - Country:US
Mailing Address - Phone:617-688-5165
Mailing Address - Fax:
Practice Address - Street 1:1132 WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3878
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:413-439-0096
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1062971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP00418015OtherMEDICARE RAILROAD
MAP00418015OtherMEDICARE RAILROAD