Provider Demographics
NPI:1063709806
Name:POLHAMUS, TEGAN MALLARY (LICSW)
Entity type:Individual
Prefix:
First Name:TEGAN
Middle Name:MALLARY
Last Name:POLHAMUS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:TEGAN
Other - Middle Name:MALLARY
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 BLACKBURN CENTER
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-5040
Mailing Address - Country:US
Mailing Address - Phone:978-283-7793
Mailing Address - Fax:
Practice Address - Street 1:3 BLACKBURN CENTER
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930
Practice Address - Country:US
Practice Address - Phone:978-283-7793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA221026104100000X
MA120986104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker