Healthcare Provider Details

I. General information

NPI: 1972802353
Provider Name (Legal Business Name): MARLA ANN OHANESIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MYSTIC AVE
MEDFORD MA
02155-4632
US

IV. Provider business mailing address

151 MYSTIC AVE
MEDFORD MA
02155-4632
US

V. Phone/Fax

Practice location:
  • Phone: 781-396-1199
  • Fax:
Mailing address:
  • Phone: 781-396-1199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number216155
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: