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NPI Code Detail

MEDICARE: MARJORIE PROVOST GOLDBAUM LICSW LADC

MEDICARE: MARJORIE PROVOST GOLDBAUM LICSW LADC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker110711MA
2101YA0400XAddiction (Substance Use Disorder) Counselor1530MA

General Provider Information

NPI Number : 1407869704
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARJORIE PROVOST GOLDBAUM LICSW LADC
Provider Business Mailing Address
First Line : 201 CHELMSFORD ST
Second Line :
City : CHELMSFORD
State : MA
Zip : 01824-2359
Country : US
Telephone Number : 978-256-1467
Fax Number : 978-256-7465
Provider Business Practice Location Address
First Line : 201 CHELMSFORD ST
Second Line :
City : CHELMSFORD
State : MA
Zip : 01824-2359
Country : US
Telephone Number : 978-256-1467
Fax Number : 978-256-7465
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/15/2006
Last Update Date : 02/02/2016

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Directions to “ MARJORIE PROVOST GOLDBAUM LICSW LADC” Practice Location

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