Healthcare Provider Details

I. General information

NPI: 1639360605
Provider Name (Legal Business Name): MARYKATE P SHORTER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 OCEAN AVE. MGH-REVERE HEALTHCARE CENTER
REVERE MA
02151
US

IV. Provider business mailing address

416 MARLBOROUGH ST APT 708
BOSTON MA
02115-1507
US

V. Phone/Fax

Practice location:
  • Phone: 781-485-6100
  • Fax:
Mailing address:
  • Phone: 617-510-9458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111447
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: