Provider Demographics
NPI:1992892988
Name:HEINO, MARILYN GRACE (LICSW)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:GRACE
Last Name:HEINO
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 1:81 STRATHMORE RD
Mailing Address - Street 2:#22
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-7109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:264 BEACON ST
Practice Address - Street 2:FIFTH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-1236
Practice Address - Country:US
Practice Address - Phone:617-731-0535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10197581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
080313OtherVALUE OPTIONS
MAP06157Medicare ID - Type Unspecified