Basic Information
| Provider Information | |||||||||
| NPI: | 1932622875 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | INKPEN | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | SEARY | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 CHAPEL PL | ||||||||
| Address2: | |||||||||
| City: | WELLESLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024813130 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 675 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024510602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818932003 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 000222481 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.