Healthcare Provider Details

I. General information

NPI: 1609200260
Provider Name (Legal Business Name): MISS MACKENZIE FAY CUDDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2013
Last Update Date: 05/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 AMORY ST SUITE 3
JAMAICA PLAIN MA
02130-2652
US

IV. Provider business mailing address

555 AMORY ST SUITE 3
JAMAICA PLAIN MA
02130-2652
US

V. Phone/Fax

Practice location:
  • Phone: 774-254-5134
  • Fax:
Mailing address:
  • Phone: 774-254-5134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: