Provider Demographics
NPI:1104914936
Name:O'HANLEY, MARY H (MSW, LICSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:H
Last Name:O'HANLEY
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WATERTOWN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-6331
Mailing Address - Country:US
Mailing Address - Phone:781-862-5997
Mailing Address - Fax:
Practice Address - Street 1:113 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-3603
Practice Address - Country:US
Practice Address - Phone:617-620-8892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1043081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1854666Medicaid
MAP23918Medicare NSC