Provider Demographics
NPI:1912074071
Name:GLEESON, MARY KAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY KAY
Middle Name:
Last Name:GLEESON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:GLEESON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:7 KIMBALL LANE
Mailing Address - Street 2:BUILDING E, SUITE 3B
Mailing Address - City:LYNNFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01940-2617
Mailing Address - Country:US
Mailing Address - Phone:781-224-4120
Mailing Address - Fax:
Practice Address - Street 1:7 KIMBALL LANE
Practice Address - Street 2:BUILDING E, SUITE 3B
Practice Address - City:LYNNFIELD
Practice Address - State:MA
Practice Address - Zip Code:01940-2617
Practice Address - Country:US
Practice Address - Phone:781-224-4120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7568103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
20-2456932OtherEIN NUMBER
20-2456932OtherEIN NUMBER