Provider Demographics
NPI:1740643345
Name:WOOTEN, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WOOTEN
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 1:143 HIGHLAND AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-3409
Mailing Address - Country:US
Mailing Address - Phone:207-577-4850
Mailing Address - Fax:
Practice Address - Street 1:143 HIGHLAND AVE APT 1
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420
Practice Address - Country:US
Practice Address - Phone:207-577-4850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB01010787 00OtherBOSTON MEDICAL CENTER HEALTHNET PLAN
MA100214979047OtherMASSHEALTH