Provider Demographics
NPI:1134390669
Name:RAY, MARILYN A (LICSW)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:A
Last Name:RAY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:A
Other - Last Name:OHEARN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:585 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-1906
Mailing Address - Country:US
Mailing Address - Phone:508-831-0045
Mailing Address - Fax:508-735-5051
Practice Address - Street 1:76 SUMMER ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-5783
Practice Address - Country:US
Practice Address - Phone:978-343-2433
Practice Address - Fax:978-343-0791
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1032768101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1306421Medicaid
MA1308785Medicaid