Provider Demographics
NPI:1578033379
Name:KEARNS, MARK (LICSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KEARNS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 SPALLUS RD
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-2749
Mailing Address - Country:US
Mailing Address - Phone:603-498-5796
Mailing Address - Fax:
Practice Address - Street 1:170 MORTON ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3735
Practice Address - Country:US
Practice Address - Phone:617-971-3369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical