=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083106918
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAURA ADRIAN LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2018
-----------------------------------------------------
Last Update Date | 06/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2014 WASHINGTON ST
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02462-1699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-243-6695
-----------------------------------------------------
Fax | 617-243-6873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 BLACKSMITH DR
-----------------------------------------------------
City | MEDFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02052-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-654-1734
-----------------------------------------------------
Fax | 617-243-6873
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 1019465
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------