Healthcare Provider Details

I. General information

NPI: 1699358267
Provider Name (Legal Business Name): MARISA LYCURGUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PROSPECT ST STE 202
NASHUA NH
03060-3922
US

IV. Provider business mailing address

10 PROSPECT ST
NASHUA NH
03060-3922
US

V. Phone/Fax

Practice location:
  • Phone: 781-551-0999
  • Fax: 781-551-3396
Mailing address:
  • Phone: 603-886-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number231105
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number115269
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: