Provider Demographics
NPI:1588026843
Name:MEDALIE, MARSHA
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:
Last Name:MEDALIE
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 1:270 BRIDGE ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1798
Mailing Address - Country:US
Mailing Address - Phone:781-320-5328
Mailing Address - Fax:
Practice Address - Street 1:270 BRIDGE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1798
Practice Address - Country:US
Practice Address - Phone:781-320-5328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA100728104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker