=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821186693
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARC ENGRAM LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 MAIN ST STE 2A
-----------------------------------------------------
City | NORTHAMPTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01060-3170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-587-0444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 292 PELHAM HILL RD
-----------------------------------------------------
City | SHUTESBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01072-9748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-587-0444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 1023561
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------