Provider Demographics
NPI:1669544235
Name:PROVENCHER, MARY ELLEN (LICSW)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:PROVENCHER
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 1:16 CLEAR POND DRIVE
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-4310
Mailing Address - Country:US
Mailing Address - Phone:508-660-1971
Mailing Address - Fax:
Practice Address - Street 1:789 CAPBOARDTREE ST
Practice Address - Street 2:HARBOR COUNSELING CENTER
Practice Address - City:WESTWOOD
Practice Address - State:MA
Practice Address - Zip Code:02090
Practice Address - Country:US
Practice Address - Phone:781-234-1318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1007551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical