Provider Demographics
NPI:1285792457
Name:NILES, HEATHER LYN (LICSW)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:LYN
Last Name:NILES
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SWANTON ST
Mailing Address - Street 2:#T28
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-1951
Mailing Address - Country:US
Mailing Address - Phone:617-512-6350
Mailing Address - Fax:
Practice Address - Street 1:259 WATER ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-2543
Practice Address - Country:US
Practice Address - Phone:781-507-6217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1116201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical