Provider Demographics
NPI:1104907732
Name:DEYAB, MARK A (LICSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:DEYAB
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 WAREHAM ST
Mailing Address - Street 2:APT. 1
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6222
Mailing Address - Country:US
Mailing Address - Phone:781-799-3949
Mailing Address - Fax:
Practice Address - Street 1:20 HOPE AVE
Practice Address - Street 2:G-05
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2721
Practice Address - Country:US
Practice Address - Phone:781-799-3949
Practice Address - Fax:781-899-6386
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111824101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health