Provider Demographics
NPI:1659415396
Name:HENRY, MARY ELLEN (PHD,LICSW)
Entity Type:Individual
Prefix:DR
First Name:MARY ELLEN
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:PHD,LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:PROVINCETOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02657-1912
Mailing Address - Country:US
Mailing Address - Phone:508-487-2698
Mailing Address - Fax:
Practice Address - Street 1:50 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657-1912
Practice Address - Country:US
Practice Address - Phone:508-487-2698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10283571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07319OtherBLUE CROSS PROVIDER NUMBE
MA1858483OtherMASSHEALTH PROVIDER NUMBE
MA1894862Medicaid
MA1894862Medicaid