Provider Demographics
NPI:1295718542
Name:DWYER, MARY ELLEN
Entity type:Individual
Prefix:MS
First Name:MARY ELLEN
Middle Name:
Last Name:DWYER
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 1:1051 BEACON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5622
Mailing Address - Country:US
Mailing Address - Phone:617-734-9300
Mailing Address - Fax:
Practice Address - Street 1:1051 BEACON ST STE 101
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5622
Practice Address - Country:US
Practice Address - Phone:617-734-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1079021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1858459Medicaid
MA1858459Medicaid