Provider Demographics
NPI:1811900301
Name:MENCO, HENRIETTA MIRIAM (MSW)
Entity type:Individual
Prefix:MS
First Name:HENRIETTA
Middle Name:MIRIAM
Last Name:MENCO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 SOUTH ST
Mailing Address - Street 2:SUITE 201A
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-3594
Mailing Address - Country:US
Mailing Address - Phone:781-696-5235
Mailing Address - Fax:781-893-8292
Practice Address - Street 1:32 SOUTH ST
Practice Address - Street 2:SUITE 201A
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-3594
Practice Address - Country:US
Practice Address - Phone:781-696-5235
Practice Address - Fax:781-893-8292
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1054151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP03960OtherBC/BS
MAP23299Medicare ID - Type UnspecifiedPART B