Healthcare Provider Details

I. General information

NPI: 1427754779
Provider Name (Legal Business Name): MARY THERESE IBRAHIM LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY GIURGUIS

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 N MAIN ST
NATICK MA
01760-1108
US

IV. Provider business mailing address

250 N MAIN ST
NATICK MA
01760-1108
US

V. Phone/Fax

Practice location:
  • Phone: 339-237-1077
  • Fax:
Mailing address:
  • Phone: 339-237-1077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW1141362
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number228916
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: