Healthcare Provider Details

I. General information

NPI: 1891807392
Provider Name (Legal Business Name): MARY M LYONS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 PORTER ST
EAST BOSTON MA
02128-2116
US

IV. Provider business mailing address

1512 FERNCROFT TOWERS
DANVERS MA
01923-4031
US

V. Phone/Fax

Practice location:
  • Phone: 617-569-3189
  • Fax: 617-569-7890
Mailing address:
  • Phone: 978-777-6332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1027728
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: