Provider Demographics
NPI:1669956611
Name:CONWAY, ILENE
Entity type:Individual
Prefix:
First Name:ILENE
Middle Name:
Last Name:CONWAY
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 1:17 ALDERBROOK DR
Mailing Address - Street 2:
Mailing Address - City:TOPSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01983-2301
Mailing Address - Country:US
Mailing Address - Phone:781-334-5743
Mailing Address - Fax:
Practice Address - Street 1:17 ALDERBROOK DR
Practice Address - Street 2:
Practice Address - City:TOPSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01983-2301
Practice Address - Country:US
Practice Address - Phone:781-334-5743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-15
Last Update Date:2018-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA120136-SW-LICSW104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA$$$$$$$$$Medicaid