Provider Demographics
NPI:1720063035
Name:WEINER, MARSHA S (LICSW)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:S
Last Name:WEINER
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 1:110 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5521
Mailing Address - Country:US
Mailing Address - Phone:508-894-0400
Mailing Address - Fax:508-565-0157
Practice Address - Street 1:110 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5521
Practice Address - Country:US
Practice Address - Phone:508-894-0400
Practice Address - Fax:508-565-0157
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110638104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
P22363Medicare ID - Type Unspecified