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NPI Code Detail

MEDICARE: MRS. AUDREY R ELY L.I.C.S.W.

MEDICARE: MRS. AUDREY R ELY L.I.C.S.W.
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
11041C0700XClinical Social Worker100333MA

General Provider Information

NPI Number : 1417989088
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. AUDREY R ELY L.I.C.S.W.
Provider Business Mailing Address
First Line : 47 VILLAGE AVE
Second Line : APT 204
City : DEDHAM
State : MA
Zip : 02026-4200
Country : US
Telephone Number : 781-461-1902
Fax Number :
Provider Business Practice Location Address
First Line : 859 WILLARD ST
Second Line : SUITE 430
City : QUINCY
State : MA
Zip : 02169-7482
Country : US
Telephone Number : 617-847-1976
Fax Number : 617-786-9894
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/06/2006
Last Update Date : 07/08/2007

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