Provider Demographics
NPI:1063574770
Name:LAX, NANCY B (MSW)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:B
Last Name:LAX
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 AYER RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:HARVARD
Mailing Address - State:MA
Mailing Address - Zip Code:01451-1133
Mailing Address - Country:US
Mailing Address - Phone:978-772-6100
Mailing Address - Fax:978-772-6980
Practice Address - Street 1:249 AYER RD
Practice Address - Street 2:SUITE 204
Practice Address - City:HARVARD
Practice Address - State:MA
Practice Address - Zip Code:01451-1133
Practice Address - Country:US
Practice Address - Phone:978-772-6100
Practice Address - Fax:978-772-6980
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1047521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO2913Medicare UPIN