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General NPI Number Information
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NPI Number | 1104907732
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Entity Type | Individual
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Provider Name | MARK A DEYAB LICSW
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Gender | Male
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 03/17/2009
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Provider Practice Location Address
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Address Line | 20 HOPE AVE G-05
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City | WALTHAM
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State | MA
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Zip | 02453-2721
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Country | US
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Telephone | 781-799-3949
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Fax | 781-899-6386
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Provider Business Mailing Address
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Address Line | 34 WAREHAM ST APT. 1
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City | MEDFORD
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State | MA
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Zip | 02155-6222
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Country | US
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Telephone | 781-799-3949
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 111824
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License Number State | MA
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