Healthcare Provider Details

I. General information

NPI: 1740622760
Provider Name (Legal Business Name): MARCIA LYNN GUPTA LICSW, EDM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARCIA LYNN WILLIAMS LCSW, EDM

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 DIMOCK ST
ROXBURY MA
02119-1029
US

IV. Provider business mailing address

55 DIMOCK ST
ROXBURY MA
02119-1029
US

V. Phone/Fax

Practice location:
  • Phone: 617-442-8800
  • Fax:
Mailing address:
  • Phone: 617-442-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number119557
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: