Provider Demographics
NPI:1104117506
Name:MCAVOY, DIANE MARIE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:MCAVOY
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 1:395 WASHINGTON ST
Mailing Address - Street 2:SUITE #8
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-4456
Mailing Address - Country:US
Mailing Address - Phone:781-326-4110
Mailing Address - Fax:508-203-5163
Practice Address - Street 1:395 WASHINGTON ST
Practice Address - Street 2:SUITE #8
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-4456
Practice Address - Country:US
Practice Address - Phone:781-326-4110
Practice Address - Fax:508-203-5163
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA114780101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health