Provider Demographics
NPI:1063600856
Name:COUGHLIN, MARY ELLEN (LICSW)
Entity type:Individual
Prefix:MS
First Name:MARY ELLEN
Middle Name:
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 FAIRMONT ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-8717
Mailing Address - Country:US
Mailing Address - Phone:781-643-0012
Mailing Address - Fax:781-643-0111
Practice Address - Street 1:805 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-1907
Practice Address - Country:US
Practice Address - Phone:781-215-1655
Practice Address - Fax:781-643-0111
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1112171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical