Provider Demographics
NPI:1972631778
Name:WISE, MARILYN GWEN (LICSW)
Entity type:Individual
Prefix:PROF
First Name:MARILYN
Middle Name:GWEN
Last Name:WISE
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 1:31 MOUNT VERNON ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2702
Mailing Address - Country:US
Mailing Address - Phone:617-497-4137
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST. WAC 037
Practice Address - Street 2:MGH
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-2617
Practice Address - Fax:617-726-1042
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1057691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical