Healthcare Provider Details

I. General information

NPI: 1871540591
Provider Name (Legal Business Name): LYNNE M. MERL LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 CITY HALL MALL
MEDFORD MA
02155-4754
US

IV. Provider business mailing address

147 MILK ST PROVIDER ENROLLMENT 9TH FLOOR
BOSTON MA
02109-4806
US

V. Phone/Fax

Practice location:
  • Phone: 781-306-5463
  • Fax:
Mailing address:
  • Phone: 617-559-8051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104692
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: