Provider Demographics
NPI:1649260282
Name:HAGGERTY, MARYJO B (LICSW DIPLOMATE)
Entity type:Individual
Prefix:MRS
First Name:MARYJO
Middle Name:B
Last Name:HAGGERTY
Suffix:
Gender:F
Credentials:LICSW DIPLOMATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PARTRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:MA
Mailing Address - Zip Code:01773-1803
Mailing Address - Country:US
Mailing Address - Phone:781-289-8606
Mailing Address - Fax:978-441-9351
Practice Address - Street 1:77 E MERRIMACK ST
Practice Address - Street 2:SUITE 23
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1251
Practice Address - Country:US
Practice Address - Phone:978-452-3711
Practice Address - Fax:978-441-9351
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASW101178103T00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA009132OtherHARV PILGRIM
240093OtherMBC
MA009132OtherHARV PILGRIM
240093OtherMBC