Provider Demographics
NPI:1306946983
Name:TAFT, MARY LOUISE (MSW, LICSW)
Entity type:Individual
Prefix:MRS
First Name:MARY LOUISE
Middle Name:
Last Name:TAFT
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 811
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:RI
Mailing Address - Zip Code:02871-0811
Mailing Address - Country:US
Mailing Address - Phone:401-683-0920
Mailing Address - Fax:
Practice Address - Street 1:11 KING CHARLES DR
Practice Address - Street 2:SUITE A4A
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-1364
Practice Address - Country:US
Practice Address - Phone:401-683-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW000681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7425-2OtherBLUE CROSS PROVIDER NUMBE
RIROO2362OtherTRICARE
RIROO2362OtherTRICARE