Basic Information
| Provider Information | |||||||||
| NPI: | 1396969465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | |||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 BRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024217927 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 BRIDGE ST | ||||||||
| Address2: | THE SIMPSON BLOCK | ||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018521201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818716550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1017881 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.