Provider Demographics
NPI:1285069047
Name:EJAIFE, MARY
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:
Last Name:EJAIFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 E MEADOW LN
Mailing Address - Street 2:APT 80
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-1556
Mailing Address - Country:US
Mailing Address - Phone:978-459-0389
Mailing Address - Fax:
Practice Address - Street 1:17 E MEADOW LN
Practice Address - Street 2:APT 80
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-1556
Practice Address - Country:US
Practice Address - Phone:978-459-0389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health