Provider Demographics
NPI:1295894210
Name:MIRICK, REBECCA GENEVIEVE (LICSW)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:GENEVIEVE
Last Name:MIRICK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3921
Mailing Address - Country:US
Mailing Address - Phone:781-435-1498
Mailing Address - Fax:
Practice Address - Street 1:338 MAIN ST
Practice Address - Street 2:SUITE 304
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-5013
Practice Address - Country:US
Practice Address - Phone:781-246-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1120531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical