Provider Demographics
NPI:1952409633
Name:MCGOWAN, MARYELLEN (LICSW)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:MCGOWAN
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 1:88 HOLDER LN
Mailing Address - Street 2:
Mailing Address - City:WEST BARNSTABLE
Mailing Address - State:MA
Mailing Address - Zip Code:02668-1814
Mailing Address - Country:US
Mailing Address - Phone:508-428-5960
Mailing Address - Fax:
Practice Address - Street 1:310 BARNSTABLE RD
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-2902
Practice Address - Country:US
Practice Address - Phone:617-847-1950
Practice Address - Fax:617-774-1490
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1040171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2205305OtherCIGNA BEHAVIORAL HEALTH
5545289OtherFIRST HEALTH/CCN
5545289OtherFIRST HEALTH/CCN