Healthcare Provider Details

I. General information

NPI: 1821186693
Provider Name (Legal Business Name): MARC ENGRAM LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MAIN ST STE 2A
NORTHAMPTON MA
01060-3170
US

IV. Provider business mailing address

292 PELHAM HILL RD
SHUTESBURY MA
01072-9748
US

V. Phone/Fax

Practice location:
  • Phone: 413-587-0444
  • Fax:
Mailing address:
  • Phone: 413-587-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1023561
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: