Provider Demographics
NPI:1982097754
Name:REZAZADEH, MARYAM (PHD)
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:REZAZADEH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 OAK MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:MA
Mailing Address - Zip Code:01773-2214
Mailing Address - Country:US
Mailing Address - Phone:617-758-9786
Mailing Address - Fax:
Practice Address - Street 1:200 BAKER AVE STE 203
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2170
Practice Address - Country:US
Practice Address - Phone:781-646-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11879103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical