MEDICARE: MRS. DOMINIQUE SIMONE DEMARSH LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	113505	MA

General Provider Information

NPI Number	:	1114430048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DOMINIQUE SIMONE DEMARSH LICSW

Provider Business Mailing Address
First Line	:	39 ALLEN PL
Second Line	:
City	:	SCITUATE
State	:	MA
Zip	:	02066-1301
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	234 COPELAND ST FL 3
Second Line	:
City	:	QUINCY
State	:	MA
Zip	:	02169-4082
Country	:	US
Telephone Number	:	781-386-7141
Fax Number	:	617-479-4798

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2017
Last Update Date	:	11/14/2017

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Directions to “ MRS. DOMINIQUE SIMONE DEMARSH LICSW” Practice Location

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