=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285645192
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRISCILLA M MAHONEY LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 62 DERBY ST STE 13
-----------------------------------------------------
City | HINGHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-749-4600
-----------------------------------------------------
Fax | 781-741-8341
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57 EISENHOWER CIR
-----------------------------------------------------
City | WELLESLEY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-235-0081
-----------------------------------------------------
Fax | 781-235-0081
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1022695
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------