Provider Demographics
NPI:1215082508
Name:GREENBLATT, MARK R (LICSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:GREENBLATT
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 1:22 FORRESTER ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-4002
Mailing Address - Country:US
Mailing Address - Phone:978-744-8428
Mailing Address - Fax:978-336-8450
Practice Address - Street 1:70 WASHINGTON ST
Practice Address - Street 2:SUITE 316
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-3518
Practice Address - Country:US
Practice Address - Phone:978-744-8428
Practice Address - Fax:978-336-8450
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1064071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical