Provider Demographics
NPI:1124336920
Name:COLLAMORE, MARYELLEN FAIRCHILD (LICSW, LCSW, MT-BC)
Entity type:Individual
Prefix:MS
First Name:MARYELLEN
Middle Name:FAIRCHILD
Last Name:COLLAMORE
Suffix:
Gender:F
Credentials:LICSW, LCSW, MT-BC
Other - Prefix:
Other - First Name:MARYELLEN
Other - Middle Name:
Other - Last Name:FAIRCHILD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:380 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAMILTON
Mailing Address - State:MA
Mailing Address - Zip Code:01982-1310
Mailing Address - Country:US
Mailing Address - Phone:978-233-1226
Mailing Address - Fax:
Practice Address - Street 1:380 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAMILTON
Practice Address - State:MA
Practice Address - Zip Code:01982-1310
Practice Address - Country:US
Practice Address - Phone:978-233-1226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA818651041C0700X
PA09139225A00000X
MA1213571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist