Provider Demographics
NPI:1215903323
Name:SAMPLE, MARIANNE (LICSW)
Entity type:Individual
Prefix:MS
First Name:MARIANNE
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:MARIANNE
Other - Middle Name:
Other - Last Name:BESCHLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:42 AUDUBON RD
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:MA
Mailing Address - Zip Code:01867-1724
Mailing Address - Country:US
Mailing Address - Phone:781-942-0703
Mailing Address - Fax:
Practice Address - Street 1:352 PARK ST
Practice Address - Street 2:STE 208
Practice Address - City:NORTH READING
Practice Address - State:MA
Practice Address - Zip Code:01864-2158
Practice Address - Country:US
Practice Address - Phone:978-470-0520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1058881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASA-P23945Medicare ID - Type UnspecifiedCLINICAL SOCIAL WORKER