Basic Information
Provider Information | |||||||||
NPI: | 1114938479 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARVEL | ||||||||
FirstName: | CAROLYN DANA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ST. LAURENT | ||||||||
OtherFirstName: | C. DANA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LICSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 23 ROWELL AVE | ||||||||
Address2: |   | ||||||||
City: | BEVERLY | ||||||||
State: | MA | ||||||||
PostalCode: | 01915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9787129781 | ||||||||
FaxNumber: | 9789273724 | ||||||||
Practice Location | |||||||||
Address1: | 800 CUMMINGS CTR | ||||||||
Address2: | SUITE 266T | ||||||||
City: | BEVERLY | ||||||||
State: | MA | ||||||||
PostalCode: | 019156175 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9789211190 | ||||||||
FaxNumber: | 9789273724 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2006 | ||||||||
LastUpdateDate: | 01/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 110634 | MA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.