Provider Demographics
NPI:1780741561
Name:DAVIS, MARLENE J (PHD)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARLENE
Other - Middle Name:J
Other - Last Name:LEDERMAN-DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:51 ELDRED ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-1439
Mailing Address - Country:US
Mailing Address - Phone:781-862-1715
Mailing Address - Fax:
Practice Address - Street 1:45 MERRIMACK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1729
Practice Address - Country:US
Practice Address - Phone:978-459-2306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA576103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW02415Medicare UPIN