Provider Demographics
NPI:1104911007
Name:OUELLETTE, MARIE C (MSW LICSW)
Entity type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:C
Last Name:OUELLETTE
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-1737
Mailing Address - Country:US
Mailing Address - Phone:781-631-8273
Mailing Address - Fax:781-631-7264
Practice Address - Street 1:66 CLIFTON AVENUE
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945
Practice Address - Country:US
Practice Address - Phone:781-631-8273
Practice Address - Fax:781-631-7264
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASW10275331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0UP23716Medicare ID - Type Unspecified