Provider Demographics
NPI:1316420649
Name:MORAN-QUEENAN, PATRICIA MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MARIE
Last Name:MORAN-QUEENAN
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 1:11 WALSH RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-2222
Mailing Address - Country:US
Mailing Address - Phone:781-275-8098
Mailing Address - Fax:
Practice Address - Street 1:11 WALSH RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-2222
Practice Address - Country:US
Practice Address - Phone:781-275-8098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1017509-SW-LICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1017509-SW-LICSWOtherLICENSE