Provider Demographics
NPI:1821548421
Name:SIDDIQUE, MARIAM
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:SIDDIQUE
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 1:95 WEST ST
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-1819
Mailing Address - Country:US
Mailing Address - Phone:508-660-1510
Mailing Address - Fax:
Practice Address - Street 1:95 WEST ST
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-1819
Practice Address - Country:US
Practice Address - Phone:508-660-1510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid