Provider Demographics
NPI:1740622760
Name:GUPTA, MARCIA LYNN (LICSW, EDM)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:LYNN
Last Name:GUPTA
Suffix:
Gender:F
Credentials:LICSW, EDM
Other - Prefix:
Other - First Name:MARCIA
Other - Middle Name:LYNN
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, EDM
Mailing Address - Street 1:55 DIMOCK ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1029
Mailing Address - Country:US
Mailing Address - Phone:617-442-8800
Mailing Address - Fax:
Practice Address - Street 1:55 DIMOCK ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1029
Practice Address - Country:US
Practice Address - Phone:617-442-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1195571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical