Basic Information
| Provider Information | |||||||||
| NPI: | 1134390669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAY | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OHEARN | ||||||||
| OtherFirstName: | MARILYN | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LICSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 585 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016051906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088310045 | ||||||||
| FaxNumber: | 5087355051 | ||||||||
| Practice Location | |||||||||
| Address1: | 76 SUMMER ST | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014205783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783432433 | ||||||||
| FaxNumber: | 9783430791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2008 | ||||||||
| LastUpdateDate: | 03/12/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1032768 | MA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1306421 | 05 | MA | MEDICAID | 1308785 | 05 | MA | MEDICAID |