Provider Demographics
NPI:1285102970
Name:MERVYN, RACHEL ANNE (LICSW)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANNE
Last Name:MERVYN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:ANNE
Other - Last Name:GANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:780 ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2755
Mailing Address - Country:US
Mailing Address - Phone:857-654-1000
Mailing Address - Fax:857-654-1099
Practice Address - Street 1:780 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2755
Practice Address - Country:US
Practice Address - Phone:857-654-1000
Practice Address - Fax:857-654-1100
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW1229191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical